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Relationship of dependency to work resumption of patients with myocardial infarction Sayo, Gardenia Javier-Septimo 1976

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THE RELATIONSHIP OF DEPENDENCY TO WORK. RESUMPTION OF PATIENTS WITH MYOCARDIAL INFARCTION b y GARDENIA J A V I E R - S E P T I M O SAYO .Sc.N., P h i l i p p i n e Women's U n i v e r s i t y , 1965 A THESIS SUBMITTED I N P A R T I A L FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF . MASTER OF SCIENCE I N NURSING i n THE FACULTY OF GRADUATE STUDIES . S c h o o l o f N u r s i n g We a c c e p t t h i s t h e s i s as c o n f o r m i n g t o t h e r e q u i r e d s t a n d a r d THE UNIVERSITY OF B R I T I S H COLUMBIA S e p t e m b e r , 1976 (c) Gardenia Jayier-Septimo.Sayo, 1976 In p r e s e n t i n g t h i s t h e s i s in p a r t i a l f u l f i l m e n t o f the r e q u i r e m e n t s f o r an advanced degree at the U n i v e r s i t y o f B r i t i s h Co lumb ia , I a g ree that the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e and s tudy . I f u r t h e r agree t h a t p e r m i s s i o n f o r e x t e n s i v e c o p y i n g o f t h i s t h e s i s f o r s c h o l a r l y purposes may be g r a n t e d by the Head o f my Department o r by h i s r e p r e s e n t a t i v e s . It i s u n d e r s t o o d that c o p y i n g o r p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l not be a l l o w e d w i thout my w r i t t e n p e r m i s s i o n . Department o f The U n i v e r s i t y o f B r i t i s h Co lumbia 2075 Wesbrook Place Vancouver, Canada V6T 1W5 Date DCTQM7t> ABSTRACT T h i s s t u d y i n v o l v e s an i n v e s t i g a t i o n o f t h e r e l a t i o n -s h i p b e t w e e n d e p e n d e n c y a n d w o r k r e s u m p t i o n o f p a t i e n t s w i t h m y o c a r d i a l i n f a r c t i o n . I n t h e p r o c e s s o f s t u d y i n g t h i s p r o b -l e m , i n f o r m a t i o n c o n c e r n i n g t h e d i f f e r e n t l e v e l s o f d e p e n d e n c y d u r i n g t h e c o n v a l e s c e n c e t h r o u g h e m p l o y m e n t c o n t i n u u m v/as g a t h e r e d . The p u r p o s e s o f t h e s t u d y a r e t o add t o t h e b o d y o f k n o w l e d g e c o n c e r n i n g t h e c o n c e p t o f d e p e n d e n c y and t o make n u r s e s and o t h e r members o f t h e h e a l t h t e a m a w a r e o f t h e i m p l i -c a t i o n s o f d e p e n d e n c y b e h a v i o u r i n t h e p r o c e s s o f r e s u m i n g n o r m a l f u n c t i o n o f p a t i e n t s w i t h m y o c a r d i a l i n f a r c t i o n . I t s l o n g r a n g e p u r p o s e i s t o i n c r e a s e t h e s e n s e o f w e l l - b e i n g a n d a c h i e v i n g o f t h e p a t i e n t w i t h m y o c a r d i a l i n f a r c t i o n b y h e l p i n g h i m r e s u m e h i s p r o d u c t i v e r o l e , b o t h t h r o u g h t h e h e l p o f members o f t h e h e a l t h t eam a n d members o f h i s f a m i l y . The s t u d y was p l a n n e d t o t e s t t h e f o l l o w i n g h y p o t h e s e s : 1. The e m p l o y e d p a t i e n t s w i t h m y o c a r d i a l i n f a r c t i o n w i l l show ; l o w e r d e p e n d e n c y r a t i n g s t h a n t h e u n e m p l o y e d p a t i e n t s i n t h e N a v r a n Dy S c a l e . 2. The e m p l o y e d p a t i e n t s w i t h m y o c a r d i a l i n f a r c t i o n w i l l show p r o g r e s s i v e d e c r e a s e i n t h e D-I S c a l e d e p e n d e n c y r a t i n g s a l o n g t h e c o n v a l e s c e n c e t o e m p l o y m e n t p e r i o d c o n t i n u u m , w h i l e t h e u n e m p l o y e d p a t i e n t s w i t h m y o c a r d i a l i n f a r c t i o n w i l l m a i n t a i n a c o n s t a n t l e v e l o f d e p e n d e n c y r a t i n g s i n t h e D-I S c a l e a l o n g t h e c o n v a l e s c e n c e t o e m p l o y m e n t p e r i o d c o n t i n u u m . 3. Low t r a i t d e p e n d e n t s w i t h m y o c a r d i a l i n f a r c t i o n w i l l show p r o g r e s s i v e d e c r e a s e i n t h e D-I S c a l e d e p e n d e n c y r a t i n g s a l o n g t h e c o n v a l e s c e n c e t o e m p l o y m e n t p e r i o d c o n t i n u u m , w h i l e h i g h t r a i t d e p e n d e n t p a t i e n t s w i t h m y o c a r d i a l i n -f a r c t i o n w i l l c o n t i n u e t o show s t e a d y d e p e n d e n c y r a t i n g s i n t h e D-I S c a l e a l o n g t h e c o n v a l e s c e n c e t o e m p l o y m e n t p e r i o d c o n t i n u u m . i v Two s t r u c t u r e d q u e s t i o n n a i r e s w e r e c o n s t r u c t e d f o l l o w i n g a r e v i e w o f t h e l i t e r a t u r e t o o b t a i n i n f o r m a t i o n r e g a r d i n g t h e r e s e a r c h p r o b l e m . The- N a v r a n Dy and t h e d e p e n d e n c y p o r t i o n o f t h e D-I S c a l e w e r e a l s o a d m i n i s t e r e d . The s t u d y p o p u l a t i o n c o n s i s t e d o f 21 men. The s t u d y p o p u l a t i o n was r e s t r i c t e d t o men who w e r e c o n f i n e d i n t h e h o s p i t a l f o r t h e i r f i r s t myo-c a r d i a l i n f a r c t i o n , who w e r e 64 y e a r s o f age o r y o u n g e r , who c o u l d r e a d a n d w r i t e E n g l i s h , a n d who h a d b e e n e m p l o y e d f o r t h e 6 m o n t h s i m m e d i a t e l y p r i o r t o t h e c o n f i n e m e n t . A n a l y s i s o f t h e d a t a i n c l u d e d F r e q u e n c y t a b l e s , T t e s t a n d t h e Two-F a c t o r A n a l y s i s o f V a r i a n c e . The f i n d i n g s o f t h e s t u d y showed t h a t p a t i e n t s w i t h m y o c a r d i a l i n f a r c t i o n s howed d i f f e r e n t d e g r e e s o f d e p e n d e n c y , b o t h t r a i t a n d s t a t e . The f i n d i n g s f a i l e d t o s u p p o r t t h e t h r e e h y p o t h e s e s e v e n t h o u g h d u r i n g t h e d a t a a n a l y s i s o f t h e i n d i v i d u a l h y p o t h e s i s , t h e g r o u p means showed l e a n i n g t o w a r d s t h e d i r e c t i o n o f t h e h y p o t h e s i s . The s t u d y s u g g e s t s t h a t s t e p s s h o u l d b e t a k e n t o make n u r s e s and f a m i l y more a w a r e o f t h e v a r y i n g d e g r e e s o f d e p e n -d e n c y i n p a t i e n t s . 75 p a g e s ACKNOWLEDGEMENTS I w i s h t o e x p r e s s ray a p p r e c i a t i o n t o my h u s b a n d f o r h i s p a t i e n c e a n d h e l p i n c o m p l e t i n g t h i s t h e s i s . I a l s o w i s h t o t h a n k my f r i e n d s f o r t h e i r e n c o u r a g e m e n t a n d s u p p o r t . F i n a l l y , I w i s h t o t h a n k M r s . M a r i e M a c k i e , D r . Todd R o g e r s , a n d A s s i s t a n t P r o f e s s o r s H e l e n E l f e r t a n d E l i z a b e t h -La S o r f o r t h e i r i n v a l u a b l e h e l p i n m a k i n g - t h i s s t u d y p o s s i b l e . v TABLE OF CONTENTS PAGE ACKNOWLEDGEMENTS . i L I S T OF TABLES . . . . C h a p t e r I . INTRODUCTION TO THE STUDY . 1 INTRODUCTION 1 STATEMENT OF THE PROBLEM 4 PURPOSES OF THE STUDY 4 HYPOTHESES 5 SIGNIFICANCE OF THE STUDY 5 DEFINITION OF TERMS USED . 9 LIMITATIONS OF THE STUDY 11 I I . REVIEW OF THE LITERATURE 12 INTRODUCTION . . . . . . . . 12 CONCEPT OF DEPENDENCE 13 STUDIES DONE ON DEPENDENCY . . . . . . . 16 STUDIES DONE ON WORK RESUMPTION OF PATIENTS WITH MYOCARDIAL INFARCTION . 19 SUMMARY 22 I I I . RESEARCH DESIGN AND DEVELOPMENT OF THE STUDY 23 SELECTION OF THE STUDY GROUP 23 Th e S e t t i n g 23 The S u b j e c t s 25 v i v i i PAGE I n i t i a l C o n t a c t W i t h The S u b j e c t s . . . 26 INSTRUMENTATION . • 27 The S u b j e c t ' s P r o f i l e Q u e s t i o n n a i r e . . 27 The Work R e s u m p t i o n P r o f i l e Q u e s t i o n n a i r e 28 The D e p e n d e n c e / I n d e p e n d e n c e S c a l e . . . 28 The N a v r a n Dy p o r t i o n o f t h e MMPI . . . 29 PRE-TEST 30 ADMINISTRATION OF QUESTIONNAIRES . . . . . 30 S T A T I S T I C A L A N A L Y S I S 32 SUMMARY 33 I V . ANALYSIS OF THE DATA 34 TESTING HOSPITAL DIFFERENCE . . . . . . . . 34 Age 35 Number o f D a y s i n t h e C o r o n a r y C a r e U n i t 35 Number o f Days i n t h e P o s t C o r o n a r y U n i t 36 F i r s t N a v r a n Dy S c o r e s 37 TESTING THE VARIABLES 38 Age 38 Number o f Days i n t h e C o r o n a r y C a r e U n i t 39 Number o f Days i n t h e P o s t C o r o n a r y U n i t 40 TESTING THE HYPOTHESES 41 V. SUMMARY, CONCLUSIONS AND RECOMMENDATIONS . 48 SUMMARY 48 v i i i PAGE CONCLUSIONS 50 RECOMMENDATIONS 52 FOOTNOTES 53 BIBLIOGRAPHY 58 APPENDICES 64 A. C o n s e n t F o r m 65 B. I n s t r u m e n t s U s e d i n t h e S t u d y . 67 LIST OF TABLES Table Page 1. Schedule of Administration of Questionnaires . . . 32 2. Frequency D i s t r i b u t i o n of the Study Population From Two Hospitals by Age 35 3. Frequency D i s t r i b u t i o n of the Study Population From Two Hospitals by the Number of CCU Days . 36 4. Frequency D i s t r i b u t i o n of the Study Population From Two Hospitals by the Number of PCU Days . 37 5. Frequency D i s t r i b u t i o n of the Study Population From Two Hospitals by the Navran Dy Scores . . 38 6. Frequency D i s t r i b u t i o n of the Employed and Unemployed Study Population by Age 39 7. Frequency D i s t r i b u t i o n of the Employed and Unemployed Study Population by the Number of Days i n CCU 40 8. Frequency D i s t r i b u t i o n of the Employed and Unemployed Study Population by the Number of Days i n PCU . . . 41 9. Frequency D i s t r i b u t i o n of the Employed and Unemployed Study Population by t h e i r Navran Dy Scores 42 10. Frequency D i s t r i b u t i o n of the Study Population by t h e i r State Dependency Scores During F i r s t and Third Testing Occasions 44 i x X T a b l e Page 1 1 . Frequency D i s t r i b u t i o n o f t h e Employed and Unemployed Study P o p u l a t i o n by t h e i r S t a t e Dependency S c o r e s D u r i n g F i r s t and T h i r d T e s t i n g O c c a s i o n s 45 1 2 . Frequency D i s t r i b u t i o n o f t h e Low and H i g h T r a i t Study P o p u l a t i o n by t h e i r S t a t e . Dependency S c o r e s D u r i n g F i r s t and T h i r d T e s t i n g O c c a s i o n s 46 1 CHAPTER I INTRODUCTION TO THE STUDY I . INTRODUCTION I n t h e p a s t , t h e m a i n f o c u s o f t h e n u r s e h a s b e e n on t h e c a r e a n d c o m f o r t o f p a t i e n t s , a n d f o s t e r i n g t h e i r r e c o v e r y . ^ T h e s e o b j e c t i v e s h a v e b r o a d e n e d i n s c o p e t o i n c l u d e g r e a t e r a t t e n t i o n t o t h e e m o t i o n a l f a c t o r s o f t h e i l l n e s s , a n d t o t h e n e e d s o f p a t i e n t s a n d o f t h e i r f a m i l i e s 2 3 f o r t e a c h i n g a n d f o r c o u n s e l l i n g . ' The new r o l e s o f t h e n u r s e as " n u r s e s p e c i a l i s t , " " n u r s e p r a c t i t i o n e r , " a n d a s one w i t h an " e x p a n d e d r o l e , " r e q u i r e t h a t n u r s e s n o t o n l y be t h o -r o u g h l y k n o w l e d g e a b l e i n human b e h a v i o u r b u t a l s o be w e l l q u a l i f i e d t o meet t h e p h y s i c a l a n d e m o t i o n a l n e e d s o f t h e p a t i e n t b o t h i n h o s p i t a l a n d i n v a r y i n g c o m m u n i t y p l a c e m e n t s . I n m e e t i n g t h i s r e s p o n s i b i l i t y , n u r s e s a c t i n d e p e n d e n t l y i n t h e a s s e s s m e n t o f n u r s i n g p r o b l e m s , i n t h e d e c i s i o n m a k i n g r e l a t i v e t o i n t e r v e n i n g on t h e s e p r o b l e m s , a n d i n t h e e v a l u a -t i o n o f t h e e f f e c t i v e n e s s o f t h e c a r e g i v e n . I n o u r s o c i e t y , h e a r t d i s e a s e h a s become a l e a d i n g c a u s e o f d e a t h a n d d i s a b i l i t y . ' * F o r t h e n u r s e , p r e v e n t i o n o f h e a r t d i s e a s e a n d t h e c a r e a n d r e h a b i l i t a t i o n o f c a r d i a c p a t i e n t s p r e s e n t a c h a l l e n g e . T o d a y ' s c a r d i a c n u r s e i s e x -p e c t e d t o b e k n o w l e d g e a b l e a b o u t many a s p e c t s o f t h e d i s e a s e . The f o l l o w i n g a r e a s a r e o f p a r t i c u l a r i m p o r t a n c e : t h e p h y s i o -l o g y o f t h e i l l n e s s ; t h e s i g n i f i c a n c e o f l a b o r a t o r y f i n d i n g s ; 2 and the i n d i c a t i o n s , uses, and e f f e c t s o f s p e c i a l drugs, machinery, and o t h e r forms of treatment. E q u a l l y important i s knowledge o f such a s p e c t s as: the p r e v e n t i o n o f the i l l -n ess; the d e t e c t i o n of e a r l y s i g n s of d e v e l o p i n g p a t h o l o g y ; the a d m i n i s t r a t i o n o f c a r e d u r i n g the acute phase o f the i l l -n ess; the s u p e r v i s i o n and p a r t i c i p a t i o n i n r e h a b i l i t a t i v e a c t i v i t i e s of c o n v a l e s c i n g p a t i e n t s and the h e a l t h t e a c h i n g o f i n d i v i d u a l s and t h e i r f a m i l y . I t i s t h e r e f o r e i m p o r t a n t t h a t a nurse u t i l i z e knowledge o b t a i n e d from s o c i a l s c i e n c e s , p h y s i c a l s c i e n c e s and the h u m a n i t i e s i n o r d e r t o meet these numerous r o l e s added t o h e r r e s p o n s i b i l i t i e s . The s y m b o l i c importance o f the h e a r t as the " v i t a l organ" to the i n d i v i d u a l ' s sense of p h y s i c a l i n t e g r i t y has been r e c o g n i z e d throughout r e c o r d e d h i s t o r y . ^ M y o c a r d i a l i n f a r c t i o n i s the most s e r i o u s form o f h e a r t d i s e a s e t h a t a f f e c t s a l a r g e group o f c a r d i a c p a t i e n t s . Not o n l y does i t d e b i l i t a t e i t s v i c t i m s p h y s i c a l l y , b u t a l s o p s y c h o l o g i c a l l y . 6 The i l l n e s s r e q u i r e s the p a t i e n t t o be h o s p i t a l i z e d . D u r i n g the acute phase o f m y o c a r d i a l i n f a r c t i o n , the p a t i e n t does ve r y l i t t l e f o r h i m s e l f and i s dependent on those who are t a k i n g care o f him. Almost a l l of h i s b a s i c needs are met by the nurses and o t h e r h o s p i t a l p e r s o n n e l . The c r i t i c a l c o n d i -t i o n of the p a t i e n t a f t e r a m y o c a r d i a l i n f a r c t i o n , and the immediate h o s p i t a l i z a t i o n w i t h i t s accompanying r e s t r i c t e d a c t i v i t i e s and s p e c i a l c a r e , l e a d the p a t i e n t t o a c c e p t h i s e n f o r c e d dependency as a new k i n d o f normal b e h a v i o u r . 3 N u r s i n g and m e d i c a l l i t e r a t u r e h a v e made a v a i l a b l e , t o b o t h n u r s e s a n d p h y s i c i a n s , i n f o r m a t i o n a b o u t t h e p a t h o -g e n e s i s o f t h e i l l n e s s a n d v a r i o u s f a c t o r s common among t h i s g r o u p o f p a t i e n t s s u c h a s a n x i e t y , d e n i a l , d e p r e s s i o n , a n d a g g r e s s i v e b e h a v i o u r . ^ ' 1 0 , 1 1 , 1 2 T h e r e h a s b e e n l e s s a t t e n t i o n , b o t h i n l i t e r a t u r e a nd i n p r a c t i c e , t o u n d e r s t a n d i n g t h e i m p l i c a t i o n s o f t h e p a t i e n t ' s d e p e n d e n c y t h r o u g h o u t t h e i l l -n e s s a n d c o n v a l e s c e n c e p e r i o d . A l t h o u g h t h e t h r e a t t o l i f e p o s e d by m y o c a r d i a l i n f a r c t i o n i s w i d e l y r e c o g n i z e d , t h e i m p a c t o f t h e c o n d i t i o n on t h e p r e v i o u s l y p u r s u e d a c t i v i t i e s a nd t h e d e p e n d e n c y o f t h e p a t i e n t s who s u r v i v e t h e a t t a c k i s l e s s u n d e r s t o o d . I t h a s b e e n t h e w r i t e r ' s o b s e r v a t i o n when w o r k i n g a s a C o r o n a r y C a r e n u r s e t h a t v / h i l e some p a t i e n t s w i t h m y o c a r d i a l i n f a r c t i o n h a v e no p r o b l e m m a k i n g t h e t r a n s i t i o n f r o m t h e i r e n f o r c e d d e p e n d e n t r o l e o n c e t h e y a r e s t a r t e d on t h e i r r e h a -b i l i t a t i o n s t a g e , o t h e r s t e n d t o h a n g on t o t h i s d e p e n d e n c y e v e n when t h e c r i s i s i s o v e r . The w r i t e r h a s a l s o o b s e r v e d t h a t s e v e r a l o f t h e p a t i e n t s w i t h s e c o n d o r t h i r d m y o c a r d i a l i n f a r c t i o n a r e r e t i r e d e v e n t h o u g h t h e y a r e i n t h e i r f i f t i e s o r e a r l y s i x t i e s a n d a r e a b l e t o c o n t i n u e w o r k i n g . The r e v i e w o f l i t e r a t u r e f a i l e d t o come up w i t h a s t u d y s h o w i n g t h e r e -l a t i o n s h i p o f d e p e n d e n c y t o unemployment o f p a t i e n t s w i t h myo-c a r d i a l i n f a r c t i o n . L i t e r a t u r e , h o w e v e r , i n d i c a t e s t h a t some p a t i e n t s who h a v e s u f f e r e d f r o m m y o c a r d i a l i n f a r c t i o n f a i l t o resume n o r m a l f u n c t i o n i n g ( i . e . r e t u r n t o work) i n s p i t e o f m e d i c a l c l e a r a n c e t o do s o . 1 3 ' ! 4 A p e r s i s t e n c e o f t h e i r 4 dependent behaviour was common among those who did not return to work. The following questions, therefore, a r i s e : 1. Is there a r e l a t i o n s h i p between dependency and work re-sumption of patients with myocardial i n f a r c t i o n ? 2. What i s the degree of patient dependency at the d i f f e r e n t stages of the i l l n e s s ? I I . STATEMENT OF THE PROBLEM This study i s an attempt to f i n d out the re l a t i o n s h i p between dependency behaviour and work resumption of patients with myocardial i n f a r c t i o n . In the process of answering t h i s question, data concerning the degree of dependency of patients at d i f f e r e n t stages of myocardial i n f a r c t i o n w i l l also be gathered. I I I . PURPOSES OF THE STUDY This study has both immediate and long range purposes. Immediate purposes: 1. To add to the body of knowledge concerning the concept of dependency. 2. To make nurses and other members of the health team more aware of the implications of dependency behaviour on the process of resuming normal function of patients with myocardial i n f a r c t i o n . Long range purpose: To increase the sense of well-being and achieving of 5 t h e p a t i e n t w i t h m y o c a r d i a l i n f a r c t i o n b y h e l p i n g h i m r e s u m e h i s p r o d u c t i v e r o l e , b o t h t h r o u g h t h e h e l p o f members o f t h e h e a l t h t e am a n d members o f h i s f a m i l y . I V . HYPOTHESES The f o l l o w i n g a r e t h e h y p o t h e s e s o f t h e s t u d y : 1. The e m p l o y e d p a t i e n t s w i t h m y o c a r d i a l i n f a r c t i o n w i l l show l o w e r d e p e n d e n c y r a t i n g s t h a n t h e u n e m p l o y e d p a t i e n t s i n t h e N a v r a n Dy S c a l e . 2. The e m p l o y e d p a t i e n t s w i t h m y o c a r d i a l i n f a r c t i o n w i l l show p r o g r e s s i v e d e c r e a s e i n t h e D-I S c a l e d e p e n d e n c y r a t i n g s a l o n g t h e c o n v a l e s c e n c e t o e m p l o y m e n t p e r i o d c o n t i n u u m , w h i l e t h e u n e m p l o y e d p a t i e n t s w i t h m y o c a r d i a l i n f a r c t i o n w i l l m a i n t a i n a c o n s t a n t l e v e l o f d e p e n d e n c y r a t i n g s i n t h e D-I S c a l e a l o n g t h e c o n v a l e s c e n c e t o em-p l o y m e n t p e r i o d c o n t i n u u m . 3. Low t r a i t d e p e n d e n t s w i t h m y o c a r d i a l i n f a r c t i o n w i l l show p r o g r e s s i v e d e c r e a s e i n t h e D-I S c a l e d e p e n d e n c y r a t i n g s a l o n g t h e c o n v a l e s c e n c e t o e m p l o y m e n t p e r i o d c o n t i n u u m , w h i l e h i g h t r a i t d e p e n d e n t p a t i e n t s w i t h myo-c a r d i a l i n f a r c t i o n w i l l c o n t i n u e t o show s t e a d y d e p e n -d e n c y r a t i n g s i n t h e D-I S c a l e a l o n g t h e c o n v a l e s c e n c e t o e m p l o y m e n t p e r i o d c o n t i n u u m . V. S I G N I F I C A N C E OF THE STUDY Many s t u d i e s i n d i c a t e t h a t m y o c a r d i a l i n f a r c t i o n i s a v e r y s i g n i f i c a n t c a u s e o f h o s p i t a l i z a t i o n a n d d e a t h n o t o n l y i n C a n a d a b u t i n o t h e r c o u n t r i e s as w e l l . I n 1 9 7 1 , 75,851 C a n a d i a n s w e r e a f f l i c t e d w i t h m y o c a r d i a l i n f a r c t i o n , 30,95 8 o f whom d i e d . 1 5 ' 1 6 I n 1972, 77,089 s u f f e r e d f r o m t h e i l l n e s s , 17 18 31,344 o f whom d i e d . ' I f we d e d u c t t h e number o f d e a t h s , we h a v e 44,893 s u r v i v i n g p e r s o n s w i t h m y o c a r d i a l i n f a r c t i o n 6 i n 1 9 7 1 , and 54,745 i n 1 9 7 2 . Among t h e A m e r i c a n p o p u l a t i o n u n d e r t h e age o f 5 0 , m y o c a r d i a l i n f a r c t i o n i s t h e m o s t s e r i o u s f o r m o f h e a r t d i s e a s e . A t t h e age o f 5 0 , a p p r o x i m a t e l y 1 man i n 100 d e v e l o p s c o r o n a r y a r t e r y d i s e a s e d u r i n g t h e c o u r s e o f t h e y e a r . S t a t i s t i c s s u g g e s t t h a t a n a v e r a g e A m e r i c a n h a s a 1 i n 5 c h a n c e o f d e v e l o p i n g c o r o n a r y a r t e r y d i s e a s e b e f o r e t h e age o f 60.19 W i s h n i e e t a l . r e p o r t t h a t o u t o f 2 4 p a t i e n t s who h a d m y o c a r d i a l i n f a r c t i o n , 11 d i d n o t r e t u r n t o w o r k , a n d o f t h e s e , 9 f a i l e d t o r e t u r n b e c a u s e o f p s y c h o l o g i c a l r e a s o n s . 2 0 Cay e t a l . f o u n d t h a t o u t o f 154 who w e r e w o r k i n g a t t h e t i m e o f a d m i s s i o n , o n l y 94 (69%) r e t u r n e d t o w o r k a f t e r f o u r m o n t h s . 2 1 N a g l e a n d h i s c o l l e a g u e s r e p o r t e d t h a t a p p r o x i m a t e l y 50% o f t h e i r 115 p a t i e n t s h a d r e t u r n e d t o w o r k a f t e r 4 m o n t h s . 2 2 The r e m a i n i n g p e r c e n t a g e o f p a t i e n t s who do n o t go b a c k t o w o r k r e p r e s e n t s a g r e a t l o s s t o t h e i n s t i t u t i o n s a n d o r g a n i z a t i o n s w h i c h h a v e e x p e n d e d t i m e and money t o e d u c a t e t h e s e w o r k e r s . S o c i e t y a l s o s u f f e r s t h e l o s s o f t h e s e e x p e r i e n c e d w o r k e r s w hose s k i l l s a n d k n o w l e d g e w o u l d c o n t r i b u t e t o t h e g r o w t h o f t h e s o c i e t y . The f a m i l y i s d e p r i v e d o f a member who i s o r d i n -a r i l y a s i g n i f i c a n t c o n t r i b u t o r , b o t h f i n a n c i a l l y a n d e m o t i o n -a l l y t o t h e f a m i l y l i f e , a n d m o s t i m p o r t a n t o f a l l , t h e i n d i -v i d u a l i s d e p r i v e d o f t h e s a t i s f a c t i o n d e r i v e d f r o m b e i n g s e l f -s u f f i c i e n t and p r o d u c t i v e . T h e r e i s i n c r e a s i n g e v i d e n c e t h a t t h e c o m p l e x p r o b l e m o f d e p e n d e n c y i s s e e n b y some a u t h o r i t i e s a s t h e p r i m a r y t h r e a t 7 2 3 Z 4 2.5 • t o t h e a c h i e v e m e n t c a p a c i t y o f an i n d i v i d u a l . ' ' I t i s i m p o r t a n t t h a t a p e r s o n r e t u r n t o h i s f o r m e r l e v e l o f d e p e n -d e n c y i . e . n o r m a l s o c i a l and work l i f e . I n t h i s r e g a r d , i t w o u l d be s i g n i f i c a n t t o s t u d y t h e r e l a t i o n s h i p b e t w e e n d e p e n -d e n c y and work r e s u m p t i o n o f p a t i e n t s w i t h m y o c a r d i a l i n -f a r c t i o n . D a t a a b o u t t h e p a t i e n t s ' d e p e n d e n c y d u r i n g v a r i o u s s t a g e s o f t h e i l l n e s s w i l l a l s o be c o l l e c t e d d u r i n g t h e s t u d y . T h i s w i l l p r o v i d e i n f o r m a t i o n f o r n u r s e s c o n c e r n i n g t h e s i g n i f i c a n c e o f d e p e n d e n c y as a p s y c h o l o g i c a l r e a c t i o n t o i l l n e s s . The n u r s e s who a r e members o f t h e h e a l t h team i n c l o s e c o n t a c t w i t h t h e p a t i e n t s h o u l d be a b l e t o r e c o g n i z e a n d h a n d l e t h e p a t i e n t ' s d e p e n d e n c y i n a manner t h a t w i l l b e b e n e f i c i a l t o t h e p a t i e n t . I f t h e r e l a t i o n s h i p o f f a i l u r e t o r e t u r n t o work and d e p e n d e n c y i s e s t a b l i s h e d , t h e p a t i e n t ' s d e p e n d e n c y a t e a c h s t a g e o f h i s r e c o v e r y becomes v e r y i m p o r t a n t . S t u d y o f t h e p a t i e n t ' s d e p e n d e n c y d u r i n g i l l n e s s i s o f v a l u e t o n u r s e s i n t h a t i t p r o v i d e s n e c e s s a r y d a t a upon w h i c h t h e y may b a s e t h e i r a s s e s s m e n t and i n t e r v e n t i o n w i t h a g r e a t e r d e g r e e o f u n d e r s t a n d i n g o f t h e s e i n t e g r a l p a r t s o f human b e -h a v i o u r . E q u i p p e d w i t h t h i s k n o w l e d g e , t h e n u r s e w i l l be more aware o f what t h e p a t i e n t i s g o i n g t h r o u g h a t t h e d i f f e r e n t s t a g e s o f h i s i l l n e s s and t h a t p r o g r e s s i o n f r o m d e p e n d e n c e s h o u l d be made d u r i n g r e h a b i l i t a t i o n . The n u r s e w i l l b e a b l e t o u n d e r s t a n d b e t t e r t h e p a t i e n t ' s p r o b l e m s e s p e c i a l l y i f he h a s t r o u b l e r e l i n q u i s h i n g h i s d e p e n d e n t r o l e . She w i l l a l s o be a b l e t o h e l p him d e a l s u c c e s s f u l l y w i t h t h e p r o b l e m s , o r 8 be able to change her goals i f the patient has already reached his. former l e v e l of dependency but has problems resuming his former working capacity. The information, i f made av a i l a b l e , w i l l help the concerned nurse to broaden her care to include the important aspect of dealing with the whole person and not just the disease. This information i s important as we l l to the members of the family with whom the patient l i v e s during his con-valescence. The patient's family can help him more by knowing that encouraging the patient to perform appropriate tasks w i l l a i d h i s r e h a b i l i t a t i o n . The nurse should make a p a r t i c u l a r e f f o r t to work with families and s i g n i f i c a n t others to help them understand t h i s information. L a s t l y , society w i l l b e n e f i t from the input of these i n d i v i d u a l s i f they are succe s s f u l l y r e h a b i l i t a t e d to t h e i r maximum functioning capacity with t h e i r sense of achieving and well-being restored. V I . D E F I N I T I O N OF TERMS USED F o r t h e p u r p o s e o f t h i s s t u d y , t h e f o l l o w i n g t e r m s a r e d e f i n e d . P a t i e n t w i t h M y o c a r d i a l I n f a r c t i o n A p a t i e n t who s u f f e r e d n e c r o s i s o f a n a r e a o f h i s h e a r t m u s c l e as a r e s u l t o f a d e c r e a s e i n b l o o d s u p p l y due t o o c c l u s i o n o f t h e c o r o n a r y a r t e r i e s . E m p l o y e d b e f o r e A d m i s s i o n A p a t i e n t w i t h m y o c a r d i a l i n f a r c t i o n who h a s b e e n e m p l o y e d f u l l t i m e f o r t h e p a s t s i x months p r i o r t o h i s p r e s e n t a d m i s s i o n . U n e mployment F a i l u r e t o r e t u r n t o w o r k t h r e e months a f t e r d i s -c h a r g e o f a p a t i e n t w i t h m y o c a r d i a l i n f a r c t i o n who h a s b e e n e m p l o y e d b e f o r e a d m i s s i o n . E m p l o y m e n t R e t u r n t o w o r k t h r e e m o n t h s a f t e r d i s c h a r g e o f a p a t i e n t w i t h m y o c a r d i a l i n f a r c t i o n . A) F u l l t i m e E m p l o y m e n t R e s u m p t i o n o f w o r k w i t h t h e same amount o f t i m e . B) P a r t t i m e E m p l o y m e n t R e s u m p t i o n o f w o r k , b u t s p e n d i n g l e s s amount o f t i m e t h a n b e f o r e a d m i s s i o n . P o s t C o r o n a r y U n i t Any u n i t i n t h e h o s p i t a l t o w h i c h a p a t i e n t w i t h myo-c a r d i a l i n f a r c t i o n i s t r a n s f e r r e d t o f r o m t h e C o r o n a r y C a r e U n i t . 10 C o r o n a r y C a r e U n i t H o s p i t a l a c u t e c a r e u n i t w h e r e a p a t i e n t w i t h myo-c a r d i a l i n f a r c t i o n i s f i r s t a d m i t t e d d u r i n g t h e c r i t i c a l s t a g e o f t h e i l l n e s s . C o n v a l e s c e n c e t o E m p l o y m e n t P e r i o d C o n t i n u u m . P e r i o d e x t e n d i n g f r o m t h e t i m e t h e f i r s t s e t o f q u e s t i o n n a i r e s i s a n s w e r e d w h i c h i s a p p r o x i m a t e l y t h e s i x t h t o t e n t h d a y i n t h e P o s t C o r o n a r y U n i t t o t h e t i m e t h e l a s t s e t o f q u e s t i o n n a i r e s i s a n s w e r e d w h i c h i s a p p r o x i m a t e l y t h r e e m o n t h s a f t e r d i s c h a r g e . T r a i t D e p e n d e n c y A more e n d u r i n g k i n d o f d e p e n d e n c y m e a s u r e d b y t h e N a v r a n Dy S c a l e . A) H i g h T r a i t D e p e n d e n t S u b j e c t s S u b j e c t s w i t h N a v r a n Dy s c o r e s w h i c h a r e a b o v e 16. B) Low T r a i t D e p e n d e n t S u b j e c t s S u b j e c t s w i t h N a v r a n Dy s c o r e s w h i c h a r e 16 o r u n d e r . S t a t e D e p e n d e n c y A t r a n s i e n t k i n d o f d e p e n d e n c y c a u s e d by e m o t i o n a l d i s t u r b a n c e s a n d m e a s u r e d b y t h e D-I S c a l e . F i r s t T e s t i n g O c c a s i o n On t h e s i x t h t o t e n t h d a y a t t h e P o s t C o r o n a r y U n i t when t h e q u e s t i o n n a i r e s a r e a n s w e r e d b y t h e s u b j e c t s f o r t h e f i r s t t i m e . 11 S e c o n d T e s t i n g O c c a s i o n On t h e week o f d i s c h a r g e a t t h e P o s t C o r o n a r y U n i t when t h e q u e s t i o n n a i r e s a r e a n s w e r e d b y t h e s u b j e c t s f o r t h e s e c o n d t i m e . T h i r d T e s t i n g O c c a s i o n On t h e t h i r d month a f t e r d i s c h a r g e when t h e q u e s t i o n -n a i r e s a r e a n s w e r e d b y t h e s u b j e c t s f o r t h e t h i r d t i m e . V I I . L IMITATIONS OF THE STUDY The f o l l o w i n g a r e r e c o g n i z e d l i m i t a t i o n s o f t h e s t u d y : (1) The s m a l l s a m p l e o f t h e p o p u l a t i o n r e s i d e n t i n t h e g r e a t e r V a n c o u v e r a r e a s e l e c t e d f r o m two h o s p i t a l s r e s t r i c t e d t h e f i n -d i n g s o f t h e s t u d y t o t h e s a m p l e o n l y . The r e s u l t c a n n o t b e g e n e r a l i z e d t o o t h e r p o p u l a t i o n s . (2) The r e s t r i c t i o n o f s a m p l e t o t h o s e who a r e 64 y e a r s o l d o r y o u n g e r , who c o u l d r e a d a n d w r i t e E n g l i s h , who w e r e e m p l o y e d s i x m o n t h s p r i o r t o a d m i s s i o n , a nd who h a d n o o t h e r m a j o r i l l -n e s s e s l i m i t s t h e f i n d i n g s o f t h e s t u d y t o t h e s a m p l e o n l y . The r e s u l t i s n o t r e p r e s e n t a t i v e o f o t h e r p o p u l a t i o n s w i t h d i f f e r e n t c h a r a c t e r i s t i c s . (3) The d a t a - c o l l e c t i o n was d o n e o n c e a f t e r d i s c h a r g e o n l y . T h e r e f o r e , t h e r e s u l t i s n o t r e p r e s e n t a t i v e o f t h e c h a n g e s t h a t m i g h t h a v e h a p p e n e d a f t e r t h e q u e s t i o n n a i r e s w e r e a n s w e r e d t h r e e m o n t h s a f t e r d i s c h a r g e . 12 CHAPTER I I REVIEW OF THE LITERATURE INTRODUCTION A l t h o u g h few r e f e r e n c e s h a d b e e n made on t h e c o n c e p t o f d e p e n d e n c e , i t was n o t u n t i l t h e 195 0 ' s t h a t t h e c o n c e p t a r o u s e d s u f f i c i e n t i n t e r e s t t o w a r r a n t t h e u n d e r t a k i n g o f s e v e r a l s t u d i e s . The s t u d i e s done on t h i s a r e a w e r e m o s t l y on p r e s c h o o l a n d s c h o o l a g e d c h i l d r e n . I t was n o t u n t i l t h e l a s t few y e a r s t h a t d e p e n d e n c e h a s b e e n r e l a t e d t o i l l n e s s and r e h a b i l i t a t i o n . ' On t h e o t h e r h a n d , u n e m p l o y m e n t o f m y o c a r d i a l i n f a r c -t i o n i s m o d e r a t e l y s t u d i e d . I t h a d b e e n l i n k e d t o p h y s i c a l c o n d i t i o n i n g , s o c i o - e c o n o m i c a n d p e r s o n a l i t y f a c t o r s . T h e r e a r e , h o w e v e r , no s t u d i e s a v a i l a b l e c o n c e r n i n g t h e r e l a t i o n s h i p o f d e p e n d e n c e t o w o r k r e s u m p t i o n o f p a t i e n t s w i t h m y o c a r d i a l i n f a r c t i o n . The l i t e r a t u r e r e v i e w e d h a s b e e n s u m m a r i z e d i n t o t h r e e m a i n h e a d i n g s : 1. C o n c e p t o f D e p e n d e n c e 2. S t u d i e s Done on D e p e n d e n c e 3. S t u d i e s Done on Unemployment o f P a t i e n t s w i t h M y o c a r d i a l I n f a r c t i o n 13 I . CONCEPT OF DEPENDENCE My c o n c e p t o f d e p e n d e n c e o n w h i c h t h i s s t u d y i s t h e o -r e t i c a l l y b a s e d , i s d r a w n f r o m many d i s c i p l i n e s s u c h a s s o c i o l o g y , d e v e l o p m e n t a l p s y c h o l o g y , a n d p s y c h o a n a l y s i s . L i k e B e l l e r , I b e l i e v e t h a t d e p e n d e n c e i s a c o n d i t i o n a l d r i v e t o s e e k p h y s i c a l c o n t a c t , p r o x i m i t y , a t t e n t i o n , h e l p , r e c o g -n i t i o n , a n d a p p r o v a l . 3 * I v i e w d e p e n d e n c e as o r i g i n a t i n g f r o m t h e b e g i n n i n g o f l i f e . The s u d d e n c h a n g e f r o m f o e t a l t o human e x i s t -e n c e b y t h e c u t o f t h e u m b i l i c a l c o r d i s o n l y r e a l i n t h e s e n s e o f t h e s e p a r a t i o n o f t h e t w o b o d i e s . The i n f a n t r e m a i n s p a r t o f t h e m o t h e r b e i n g f e d , c a r r i e d a n d t a k e n c a r e o f i n e v e r y way. The d e v e l o p m e n t o f d e p e n d e n c e i s i n f l u e n c e d b y e n v i r o n -m e n t a l f a c t o r s . I n a p p r o p r i a t e d e p e n d e n c e d e v e l o p s f r o m p r o -l o n g e d f a i l u r e t o g r a t i f y t h e n e e d s o f a c h i l d , b o t h p h y s i c a l a n d p s y c h o l o g i c a l , i n h i s e a r l y y e a r s o f l i f e . When s u c h l o v e a n d a t t e n t i o n a r e d e n i e d , t h e f r u s t r a t i o n p r o d u c e s a vacuum w h i c h t h e i n d i v i d u a l t r i e s t o f i l l b y i n d e p e n d e n t b e h a v i o u r . On t h e o t h e r h a n d , o v e r g r a t i f i c a t i o n o f demands d u r i n g d e v e l o p -m ent p e r i o d c a n h e i g h t e n d e p e n d e n t s t r i v i n g s i n a c h i l d . ^ 4 D u r i n g a d o l e s c e n c e , a m a j o r b i d f o r f r e e d o m i s made. D u r i n g t h e p r o c e s s , an a d o l e s c e n t o b t a i n s n e e d s a t i s f a c t i o n f r o m h i s p e e r g r o u p . C o n f l i c t a r i s e s when h i s f a m i l y f a i l s t o r e l i n q u i s h i t s d o m i n a n t r o l e i n h i s l i f e . ^ - * A s a p e r s o n p a s s e s t h r o u g h t h e d e v e l o p m e n t a l s t a g e s i n h i s l i f e , e n v i r o n m e n t a l f a c t o r s 14 c o n t i n u e t o i n f l u e n c e h i s d e p e n d e n t b e h a v i o u r . D e p e n d e n c e i s b o t h a p e r s o n a l i t y t r a i t and a t r a n s i e n t s t a t e . 3 ^ D e p e n d e n c e as a t r a i t o c c u r s i n a p e r s o n ' s e n d u r i n g p a t t e r n o f b e h a v i o u r a n d i s e x h i b i t e d i n many s i t u a t i o n s . The d e p e n d e n t s t a t e i s a t r a n s i e n t b e h a v i o u r a p e r s o n e x h i b i t s when he e n c o u n t e r s a n i r r e g u l a r l i f e c h a n g e o r a number o f l i f e c h a n g e s . O f t e n c i t e d b y a u t h o r i t i e s as l i f e c h a n g e s w h i c h c a n c a u s e d e p e n d e n c e a r e i l l n e s s , p h y s i c a l i n j u r y , h o s p i t a l i z a t i o n , 37 38 and s u r g e r y . ' • D e p e n d e n c e w h i c h i s a n i n t e g r a l p a r t o f human b e h a v i o u r , i s more p r o m i n e n t i n s p e c i a l c i r c u m s t a n c e s s u c h a s i n f a n c y , a n d c h i l d h o o d ; i n i l l n e s s ; a n d , s o m e t i m e s , i n o l d a g e . ^ R e g r e s s i o n i n t o d e p e n d e n c y i s c o n c o m i t a n t w i t h t h e i l l n e s s s t a t e . ^ I n s i c k n e s s , t h e r e i s a t e n d e n c y t o b e p a s -s i v e . T h i s may b e due t o t h e s i c k p e r s o n ' s a m b i v a l e n c e t o -w a r d s d e p e n d e n c y - i n d e p e n d e n c y w h i c h i s p r o m i n e n t i n i l l n e s s . L i k e a c h i l d , t h e p a t i e n t d u r i n g i l l n e s s e x h i b i t s g r a t e f u l n e s s , " l o v e " a n d a d m i r a t i o n t o t h e b e n e f a c t o r s , b u t a t t h e same t i m e r e s e n t s t h e m b e c a u s e o f h i s weak and i n f e r i o r r e l a t i o n t o them. The d e g r e e o f t h e i n d i v i d u a l ' s d e p e n d e n c e o r n o n - d e p e n d e n c e upon o t h e r p e r s o n s i s a f a c t o r w h i c h i n f l u e n c e s h i s r e s p o n s e t o a s i t u a t i o n o f p h y s i c a l s t r e s s . A d a p t i n g a " p a t i e n t r o l e " i n f l u e n c e s t h e d e p e n d e n c e l e v e l o f a p e r s o n b e c a u s e t h e i n a b i -l i t y t o f u n c t i o n n o r m a l l y i s p a r t i a l l y l e g i t i m i z e d i n a s i c k r o l e . I n c r e a s e d d e p e n d e n c y i s a d o m i n a n t t r e n d i n t h e p r o -c e s s o f r e c o v e r y f r o m i l l n e s s o r t r a u m a . I n o r d e r t o r e t u r n 1 5 t o an o p t i m u m l e v e l o f a c h i e v e m e n t , d e p e n d e n c e , w h i c h i s t h e p r i m a r y t h r e a t t o t h e a c h i e v e m e n t c a p a c i t y o f a c o n v a l e s c e n t p e r s o n , m u s t be o v e r c o m e . B e c a u s e d e p e n d e n c y o f d i f f e r e n t p e r s o n s v a r i e s , e a c h p a t i e n t s h o u l d b e h e l p e d i n d i v i d u a l l y t o r e a c h h i s f o r m e r l e v e l o f d e p e n d e n c e i n o r d e r t o r e s u m e h i s f o r m e r c a p a c i t y . The p e r s o n s w o r k i n g w i t h t h e p a t i e n t s h o u l d n o t e x p e c t h i m t o r e a c h a d e p e n d e n c y l e v e l w h i c h i s b e y o n d h i s f o r m e r l e v e l b e f o r e h i s i l l n e s s . R e c o v e r y i s a j o b t o b e done by t h e p a t i e n t i n c o o p -e r a t i o n w i t h h i s f a m i l y a n d w i t h t h o s e q u a l i f i e d t o h e l p h i m . The c a p a c i t y o f t h e i n d i v i d u a l t o e x e c u t e t h e b e h a v i o u r e x p e c -t e d o f h i m a n d t o p e r f o r m t a s k s t o w h i c h he h a s b e e n s o c i a l i z e d , m u s t be r e i n s t a t e d . R e h a b i l i t a t i o n i n v o l v e s h e l p i n g t h e i n d i -v i d u a l r e t u r n t o h i s p r e v i o u s r o l e s , i n c l u d i n g r e t u r n i n g t o work.** N u r s e s , as w e l l a s o t h e r members o f t h e h e a l t h t e a m , m u s t r e c o g n i z e d e p e n d e n c y o f t h e c l i e n t a n d h a n d l e t h e s i t u a -t i o n b a s e d o n t h o r o u g h k n o w l e d g e o f t h e c o n c e p t . I n h e r a s s e s s -ment a n d i n t e r v e n t i o n , s h e m u s t be aware o f t h e p a t i e n t ' s n e e d f o r d e p e n d e n c y . N u r s e s s h o u l d be a b l e t o a s s i s t p a t i e n t s t o -w a r d b e h a v i o u r w h i c h p r o m o t e s h e a l t h and t o w a r d i n c r e a s i n g p e r f o r m a n c e o f t h e i r s o c i a l i z e d t a s k s . T h e y s h o u l d p r o v i d e o p p o r t u n i t y f o r t h e p a t i e n t s t o r e l e a r n o l d o r t o l e a r n new b e h a v i o u r s w h i c h c o n t r i b u t e t o t h e i r n o r m a l f u n c t i o n i n g . The n u r s e r e c o g n i z e s t h e c l i e n t ' s d e p e n d e n t p e r i o d o f i l l n e s s , a s s e s s e s and d i a g n o s e s h i s n e e d f o r d e p e n d e n c y f r o m 16 t h e b e g i n n i n g o f i l l n e s s a n d h o s p i t a l i z a t i o n . She i n t e r v e n e s i n s u c h a way t h a t e n a b l e s t h e c l i e n t t o r e l i n q u i s h d e p e n d e n c y g r a d u a l l y s o t h a t t h e c l i e n t i s more l i k e l y t o resume h i s o p t i m a l l e v e l o f f u n c t i o n i n g when he i s d i s c h a r g e d f r o m t h e h o s p i t a l a n d d u r i n g h i s c o n v a l e s c e n c e a t home. I I . STUDIES DONE ON DEPENDENCY I n t h e few s t u d i e s t h a t h a d b e e n done on d e p e n d e n c y , t h e s c o p e h a s b e e n l i m i t e d . As m e n t i o n e d e a r l i e r , m o s t o f t h e s t u d i e s h a d b e e n done on c h i l d r e n . The l i t e r a t u r e r e v i e w h e r e d i s c u s s e s s t u d i e s done on d e p e n d e n c y d u r i n g i l l n e s s and r e -h a b i l i t a t i o n . M i k u l i c 4 4 r e p o r t e d a s t u d y o f t h e r e s u l t o f p o s i t i v e a n d n e g a t i v e r e i n f o r c e m e n t s o f n u r s i n g p e r s o n n e l t o d e p e n d e n t a n d i n d e p e n d e n t p a t i e n t b e h a v i o u r s . The r e s u l t s howed t h a t n u r s i n g p e r s o n n e l more c o n s i s t e n t l y p r o v i d e d p o s i t i v e r e i n -f o r c e m e n t f o r d e p e n d e n t p a t i e n t b e h a v i o u r s t h a n f o r i n d e p e n d e n t p a t i e n t b e h a v i o u r s . F r o m t h e O p e r a n t A p p r o a c h p o i n t o f v i e w , t h e s e r e i n f o r c e m e n t p r a c t i c e s t e n d t o i n c r e a s e t h e p a t i e n t ' s d e p e n d e n t b e h a v i o u r s a t t h e e x p e n s e o f i n d e p e n d e n t b e h a v i o u r s . G r u e n f i e l d a n d W e i s s e n b u r g 4 5 r e l a t e d d e p e n d e n c e t o j o b s a t i s f a c t i o n a n d j o b d i s s a t i s f a c t i o n a n d f o u n d t h a t f i e l d d e -p e n d e n t s c h o s e t h e i n t r i n s i c a n d e x t r i n s i c f a c t o r s as s a t i s -f i e r s a n d d i s s a t i s f i e r s w h i l e f i e l d i n d e p e n d e n t p e r s o n s c h o s e j o b f a c t o r s as s a t i s f i e r s o r d i s s a t i s f i e r s . 17 G r e e n ' s ^ 6 s t u d y o f t h e b l i n d d i s t i n g u i s h e d b e t w e e n i n s t r u m e n t a l a n d e m o t i o n a l d e p e n d e n c y . S t u d y i n g 5 6 p e r m a n -e n t l y a n d t o t a l l y b l i n d a n d 14 s i g h t e d m a l e s , h e f o u n d t h a t i n s t r u m e n t a l d e p e n d e n c e ( d e p e n d e n c e t o m e e t p h y s i c a l n e e d s ) i n c r e a s e d w i t h t i m e i n t h e b l i n d g r o u p i n d i c a t i n g t h a t t h e b l i n d p r o b a b l y l e a r n e d t h a t t h e m o s t e x p e d i t i o u s w a y o f a c h i e v i n g g o a l s w a s t o d e p e n d o n o t h e r s f o r h e l p . E m o t i o n a l d e p e n d e n c e ( d e p e n d e n c e t o m e e t e m o t i o n a l n e e d s ) d e c r e a s e d w i t h t i m e s u g g e s t i n g t h a t t h e b l i n d d e v e l o p a c o p i n g m e c h a n i s m . M e n d e l s o n e t a l . 4 ' ' f o u n d t h a t " e s s e n t i a l a l c o h o l i c s " e v i d e n c e d n o o b s e r v a b l e e x p r e s s i o n o f a g g r e s s i v e o r h o s t i l e i m p u l s e s ; t h e y a r e s u b m i s s i v e a n d c o m p l i a n t . T h e y a r e t h o s e w h o a r e u n a b l e t o c o p e a d e q u a t e l y w i t h e n v i r o n m e n t a l s t r e s s c o u p l e d w i t h t h e i r o r a l n e e d s , r e g r e s s , t h r o u g h t h e i n g e s t i o n o f a l c o h o l , t o a l e v e l a t w h i c h t h e i r n e e d s a r e m e t a n d f e e l -i n g s o f c h i l d l i k e o m n i p o t e n c e a r e a c h i e v e d . M e n d e l s o n a n d c o l l e a g u e s t h i n k t h a t i t i s a v i c i o u s c i r c l e b e c a u s e t h e m o r e f r u s t r a t i o n i s f e l t t o w a r d t h e w o r l d f o r n o t s a t i s f y i n g o r a l n e e d s , t h e m o r e t h e a l c o h o l i c t u r n s t o a l c o h o l f o r s a t i s f a c t i o n . A l c o h o l p r o d u c e s f e e l i n g s o f g u i l t , d e p e n d e n c y a n d n e e d f o r p u n i s h m e n t w h i c h i n t u r n d r i v e s t h e a l c o h o l i c b a c k t o t h e b o t t l e f o r t h e n e v e r e n d i n g s e a r c h f o r o r a l s a t i s f a c t i o n . R o b i n s o n a n d M e i n h a r d t , 4 * * i n a s t u d y o f a s i n g l e c a s e , o b s e r v e d t h a t i n t e n s e e m o t i o n a r i s i n g f r o m u n g r a t i f i e d d e p e n -d e n c y n e e d s w a s p r i m a r i l y r e s p o n s i b l e f o r t h e o c c u r r e n c e o f a c o m p l e t e h e a r t b l o c k . R e h a b i l i t a t i o n c o u n s e l l i n g w i t h t h e c a r d i a c p a t i e n t i s p a r t i c u l a r l y d i f f i c u l t b e c a u s e h i s c o n c e r n 18 w i t h h i s l i m i t a t i o n s has some b a s i s i n r e a l i t y . M o r e o v e r , t h e c a r d i a c p a t i e n t poses a d i f f i c u l t p r o b l e m w i t h r e s p e c t t o h i s own dependency c o n f l i c t b e cause o f t h e i n v i s i b i l i t y o f h i s h a n d i c a p . The c a r d i a c p a t i e n t appears no d i f f e r e n t f r o m one w i t h a n o r m al c a r d i o v a s c u l a r s y s t e m . Thus he f e e l s t h a t o t h e r s c a n n o t go a bout j u s t i f y i n g h i s dependent beha-v i o u r and d e v e l o p s c o n f l i c t between h i s need t o show i n d e p e n -d e n t b e h a v i o u r and h i s own dependent s t r i v i n g s . I n some i n s t a n c e s , i t i s n e c e s s a r y f o r t h e c o u n s e l o r t o h e l p h i s c l i e n t a c c e p t h i s f e e l i n g s o f dependency r a t h e r t h a n t o compensate f o r them. N i c h o l s and B o g d o n o f f 4 ^ p o i n t e d o u t i n t h e i r s t u d y t h a t f o r t h e c h r o n i c a l l y i l l p a t i e n t and h i s f a m i l y , t h e p a t -i e n t ' s " s i c k r o l e " c h a r a c t e r i z e d by dependency, p a s s i v i t y , r e -duced p r o t e c t i v e n e s s and r e d u c e d demands by o t h e r s , may become an " e n t r e n c h e d way o f l i f e . " The p a t i e n t may c o n s c i o u s l y o r u n c o n s c i o u s l y r e s i s t t h e p h y s i c i a n ' s e f f o r t t o r e t u r n t h e p a t i e n t t o a h e a l t h y r o l e . To m o d i f y t h i s r e s i s t e n c e , t h e a u t h o r s s u g g e s t t h a t t h e s i c k r o l e must n o t be c h a l l e n g e d . B e f o r e w o r k i n g t h r o u g h w i t h t h e p a t i e n t ' s f e a r s and a n x i e t i e s , e v e r y a t t e m p t s h o u l d be made t o h e l p him a c h i e v e a f e e l i n g o f p h y s i c a l w e l l - b e i n g . Rothberg's^O s t u d y on t h e r e l a t i o n s h i p o f dependence, a n x i e t y , and p h y s i c a l r e c o v e r y f o l l o w i n g s u r g i c a l r e p a i r o f h e r n i a among men showed t h a t t h e r e i s no r e l a t i o n s h i p between the t h r e e f a c t o r s . A l t h o u g h , i n t h e s t u d y , dependence and 19 a n x i e t y w e r e n o t f o u n d t o b e r e l a t e d , R o t h b e r g recommends t h a t a s t u d y s h o u l d b e d o n e o n s p e c i f i c f a c t o r s i n t h e h o s p i t a l i -z a t i o n s i t u a t i o n w h i c h r e s u l t s i n n o n - d e p e n d e n t s u b j e c t s r e -a c t i n g d e p e n d e n t l y d u r i n g t h e p o s t - o p e r a t i v e p e r i o d . D e r d i a r i a n a n d C l o u g h s t u d i e d d e p e n d e n c e a n d i n d e p e n -d e n c e d u r i n g p r e h o s p i t a l i z a t i o n , p r e s u r g e r y , p o s t s u r g e r y , p r e -d i s c h a r g e a nd p o s t d i s c h a r g e o f 26 p a t i e n t s who h a d t o t a l h i p o r t o t a l k n e e r e p l a c e m e n t p r o c e d u r e s . D e p e n d e n c e a n d i n d e p e n -d e n c e l e v e l s v/ere f o u n d t o c h a n g e a l o n g t h e p r e h o s p i t a l t o p o s t d i s c h a r g e c o n t i n u u m . I I I . STUDIES DONE ON WORK RESUMPTION OF PATIENTS WITH MYOCARDIAL INFARCTION Many p e o p l e n e v e r go b a c k t o w o r k a f t e r a m y o c a r d i a l i n f a r c t i o n . How f a r t h i s i s e x p l a i n e d b y c a r d i a c d i s a b i l i t y a n d how f a r b y p s y c h o l o g i c a l p r o b l e m s a n d s o c i o - e c o n o m i c f a c -t o r s , h a s b e e n t h e o b j e c t o f s t u d i e s b y s e v e r a l r e s e a r c h e r s . T h e w o r k r e s u m p t i o n a f t e r m y o c a r d i a l i n f a r c t i o n a n d t h e s o c i o -e c o n o m i c f a c t o r s i n f l u e n c i n g i t was i n v e s t i g a t e d b y Vuopola->2 i n N o r t h e r n I r e l a n d . R e s u l t s s h o w e d t h a t more u r b a n men a n d women, more s k i l l e d w o r k e r s a n d more members o f h i g h e r s o c i a l c l a s s e s r e t u r n e d t o w o r k t h a n r u r a l r e s i d e n t s , u n s k i l l e d w o r -k e r s a n d members o f t h e l o w e r s o c i a l c l a s s e s . K e l l e r m a n 5 3 s t u d i e d c o n d i t i o n i n g i n p a t i e n t s a f t e r m y o c a r d i a l i n f a r c t i o n a n d r e a c h e d t h e s e two c o n c l u s i o n s r e g a r d -i n g r e h a b i l i t a t i o n a n d r e t u r n t o w o r k : a) a f t e r 4 m o n t h s o f 20 r e h a b i l i t a t i o n , a b o u t 8 5 % o r more o f p a t i e n t s i n a p o p u l a t i o n w h i c h h a d n o t r e t u r n e d t o w o r k b e c a u s e o f a n g i n a l p a i n , m e d i -c a l m i s g u i d a n c e , f e a r a n d o t h e r p s y c h o l o g i c a l r e a s o n s , c o u l d be r e t u r n e d t o w o r k ; a n d b) p h y s i c a l c o n d i t i o n i n g r e d u c e s d r u g d e p e n d e n c y , i n c r e a s e s e m o t i o n a l s t a b i l i t y , a n d makes t h e p a t i e n t ' s l i f e more p r o d u c t i v e a n d h a p p i e r . N a g l e e t a l . a s s e s s e d t h e i n f l u e n c e o f c a r d i a c d i s a b i l i t y a n d p s y c h o l o g i c a l p r o b l e m s o f 115 p a t i e n t s a p p r o x i -m a t e l y 4 months a f t e r t h e h e a r t a t t a c k . T h i r t y o u t o f t h e 58 who w e r e o f f w o r k , h a d c o m p l e t e a b s e n c e o f c l i n i c a l s i g n s o f h e a r t damage. Of t h e 41 p a t i e n t s w i t h a n g i n a , 50% w e r e a t w o r k . The p a t i e n t s r e p o r t e d t h a t a n x i e t y a n d d e p r e s s i o n w e r e t h e m o s t common n o n - c a r d i a c r e a s o n s f o r p e r s i s t e n t i n v a l i d i s m : 55% o f p a t i e n t s s t i l l a t home w e r e s u f f e r i n g f r o m t h e s e p r o -b l e m s w h i l e o n l y 1 1 % o f t h o s e who r e t u r n e d t o w o r k r e p o r t e d t h e s e p r o b l e m s . 55 I n a s t u d y b y Cay e t a l . , o f t h e 154 p a t i e n t s who w e r e w o r k i n g a t t h e t i m e o f a d m i s s i o n , 60% r e t u r n e d t o w o r k v / i t h i n 4 months a n d 77% w e r e w o r k i n g a f t e r a y e a r . P h y s i c a l d i a g n o s i s o f t h e a c u t e a t t a c k ( m y o c a r d i a l i n f a r c t i o n o r i s c h e m i a ) made l i t t l e d i f f e r e n c e t o t h e o u t c o m e . W i t h i n 4 m o n t h s a f t e r t h e a t t a c k , a n g i n a a n d b r e a t h l e s s n e s s w e r e r e l a t e d t o a c t i v i t y o f t h o s e who r e t u r n e d t o w o r k : a f t e r a y e a r , a n g i n a d i d n o t make any d i f f e r e n c e b u t r e s t l e s s n e s s became more i m p o r t a n t . T h e r e was c o n s i d e r a b l e e m o t i o n a l d i s t u r b a n c e i n t h e g r o u p ; 2 1 a b o u t h a l f o f t h e p a t i e n t s h a d c l i n i c a l e v i d e n c e o f a n x i e t y and d e p r e s s i o n . E m o t i o n a l u p s e t , m e a s u r e d b y S S I , e s p e c i a l l y i f s e v e r e , c o n t r i b u t e d t o f a i l u r e t o r e t u r n t o w o r k w i t h i n 4 m o n t h s . Cay c o n c l u d e s : "The p a t i e n t ' s own o p i n i o n o f h i s h a n d i c a p was c o l o u r e d b y h i s e m o t i o n a l s t a t e ; p a t i e n t s who w e r e d e p r e s s e d o r a n x i o u s f o l l o w i n g t h e i r h e a r t a t t a c h w e r e l i k e l y t o r e g a r d t h e m s e l v e s a s s e v e r e l y p h y s i -c a l l y h a n d i c a p p e d . " 5 6 F i s h e r , ^ 7 i n a q u e s t i o n n a i r e s u r v e y o f 111 o r g a n i -z a t i o n s a n d i n d i v i d u a l s whose m a j o r i n t e r e s t was h e a r t d i s e a s e , f o u n d t h a t r e s p o n d e n t s , b a s e d on t h e i r c l i n i c a l e x p e r i e n c e , t h i n k t h a t 6 8% o f t h e p a t i e n t s r e t u r n t o t h e i r f o r m e r a c t i v i t i e s . An a v e r a g e o f 16% o f t h e c a r d i a c s s e e n b y t h e r e s p o n d e n t s do n o t r e t u r n t o w o r k b e c a u s e o f p s y c h o -l o g i c a l f a c t o r s . The p s y c h o l o g i c a l p r o b l e m s o f c a r d i a c s m o s t f r e q u e n t l y r e c o g n i z e d b y t h e r e s p o n d e n t s w e r e " a n x i e t y , f e a r o f s u d d e n d e a t h , a n d l o s s o f m o t i v a t i o n i n t h e i r a b i l i t y t o r e t u r n t o p r e v i o u s a c t i v i t i e s . " F i s h e r s u g g e s t s t h e n e e d f o r more e x h a u s t i v e p s y c h o l o g i c a l s t u d i e s i n a r e a s r e l a t e d t o c a r d i a c r e h a b i l i t a t i o n . 22 , SUMMARY OF LITERATURE REVIEW The r e v i e w o f l i t e r a t u r e was p r e s e n t e d i n t h r e e p a r t s . The f i r s t p a r t showed t h e w r i t e r ' s c o n c e p t o f d e p e n d e n c e d e -v e l o p e d a s a r e s u l t o f s e v e r a l t h e o r i e s f r o m t h e l i t e r a t u r e r e v i e w e d . D e p e n d e n c e i s v i e w e d a s a c o n d i t i o n a l d r i v e t o s e e k p h y s i c a l c o n t a c t s u c h as p r o x i m i t y / a t t e n t i o n , h e l p , r e -c o g n i t i o n , p r a i s e , a n d a p p r o v a l . The p r e s e n t a t i o n o f t h e c o n c e p t a l s o i n c l u d e d d e v e l o p m e n t o f d e p e n d e n c e . D e p e n d e n c e , as a t r a i t a n d as a s t a t e , was a l s o d i s c u s s e d . The s e c o n d s e c t i o n r e v i e w e d t h e l i t e r a t u r e w h i c h d e a l t w i t h t h e d i f f e r e n t s t u d i e s done on d e p e n d e n c y d u r i n g i l l n e s s a n d r e h a b i l i t a t i o n . S t u d i e s show t h e i n c r e a s i n g s i g -n i f i c a n c e o f d e p e n d e n c y d u r i n g t h e s e p e r i o d s o f human l i f e . F i n a l l y , t h e l i t e r a t u r e r e v i e w e d i n t h e t h i r d p a r t e x a m i n e d s t u d i e s done on u n e m p l o y m e n t o f p a t i e n t s w i t h myo-c a r d i a l i n f a r c t i o n . The a b s e n c e o f r e s e a r c h o n t h e a r e a o f d e p e n d e n c y a n d u n e m p l o y m e n t o f p a t i e n t s w i t h m y o c a r d i a l i n f a r c t i o n p o i n t e d t o t h e u s e f u l n e s s o f a s t u d y t h a t w i l l i n v e s t i g a t e t h e r e l a -t i o n s h i p o f t h e t w o . 23 CHAPTER I I I RESEARCH DESIGN AMD DEVELOPMENT OF THE STUDY T h i s s t u d y was c o n d u c t e d i n two m u n i c i p a l i t i e s a d j a c e n t t o V a n c o u v e r , B r i t i s h C o l u m b i a . I n f o r m a t i o n p e r -t i n e n t t o t h e s t u d y was g a t h e r e d b y means o f q u e s t i o n n a i r e s . P a t i e n t r e c o r d s o f s u b j e c t s w h i l e i n t h e h o s p i t a l w e r e r e -v i e w e d f o r m e d i c a l h i s t o r y , h e a l t h t e a c h i n g i n v o l v e d , a n d p h y s i o t h e r a p y a c t i v i t i e s . The r e c o r d s a l s o p r o v i d e d r e l e -v a n t d e m o g r a p h i c d a t a . T w e n t y - o n e p a t i e n t s a n s w e r e d t h e q u e s t i o n n a i r e s : 14 s u b j e c t s a n s w e r e d t h r e e t i m e s , t w i c e w h i l e i n t h e P o s t C o r o n a r y U n i t o f t h e h o s p i t a l , a n d o n c e i n t h e i r home t h r e e m o n t h s a f t e r d i s c h a r g e ; 4 s u b j e c t s a n s w e r e d t w i c e , o n c e d u r i n g t h e 6 t h t o 1 0 t h da y i n t h e P o s t C o r o n a r y U n i t a n d o n c e i n t h e i r home t h r e e m o n t h s a f t e r d i s c h a r g e ; 3 s u b j e c t s a n s w e r e d t w i c e , o n c e o n t h e week o f d i s c h a r g e , a n d o n c e i n t h e i r home t h r e e m o n t h s a f t e r d i s c h a r g e . I . SELECTION OF THE STUDY GROUP The S e t t i n g The s u b j e c t s w e r e c h o s e n f r o m t h e p o p u l a t i o n o f p a t i e n t s w i t h m y o c a r d i a l i n f a r c t i o n i n two g e n e r a l h o s p i t a l s w i t h t h e a p p r o v a l o f t h e h o s p i t a l a d m i n i s t r a t i o n . 24 R e q u e s t s t o c o n d u c t t h e s t u d y w e r e made t o f i v e h o s -p i t a l s i n t h e g r e a t e r V a n c o u v e r a r e a . A p e r s o n a l a p p r o a c h was made t o e i t h e r t h e d i r e c t o r o f n u r s i n g o r t h e n u r s i n g s u p e r v i s o r o f e a c h h o s p i t a l . A f t e r t h e p r e s e n t a t i o n o f t h e s t u d y p r o p o s a l t o t h e f i r s t h o s p i t a l c o n t a c t e d , b o t h t h e h o s -p i t a l a d m i n i s t r a t o r a n d t h e d i r e c t o r o f n u r s i n g g r a n t e d p e r -m i s s i o n . Two o t h e r h o s p i t a l s w e r e a s k e d b u t p e r m i s s i o n was d e n i e d . One n u r s i n g d i r e c t o r e x p l a i n e d t h a t t h e s t a f f n u r s e s o f t h e u n i t f e e l p r o t e c t i v e t o w a r d s t h e i r p a t i e n t s a n d do n o t w a n t t h e i r p a t i e n t s t o a n s w e r q u e s t i o n n a i r e s . The o t h e r d i -r e c t o r o f n u r s i n g s a i d t h a t t h e d o c t o r s i n v o l v e d f e l t t h a t t h e i r p a t i e n t s w e r e t o o s i c k t o p a r t i c i p a t e i n t h e s t u d y . A t t h e f o u r t h h o s p i t a l c o n t a c t e d , t h e p r o p o s a l was p r e s e n t e d t o t h e d o c t o r s d u r i n g t h e i r m o n t h l y m e e t i n g b y a r e p r e s e n t a t i v e o f t h e d i r e c t o r o f n u r s i n g . A p p r o v a l was g r a n t e d p r o v i d e d t h a t e a c h s u b j e c t ' s p e r s o n a l p h y s i c i a n g r a n t e d p e r m i s s i o n . T h i s a r r a n g e m e n t d i d n o t p r o v e t o be a p r o b l e m . A f t e r a n e x -p l a n a t i o n o f t h e s t u d y was g i v e n , a l l o f t h e d o c t o r s a p p r o a c h e d a l l o w e d t h e i r p a t i e n t s t o a n s w e r t h e q u e s t i o n n a i r e s . A l l o f t h e d o c t o r s w e r e aware o f t h e s t u d y b e c a u s e t h e d o c t o r s ' m o n t h l y b u l l e t i n i n c l u d e d t h e i n f o r m a t i o n t h a t a s t u d e n t f r o m t h e U n i v e r s i t y o f B r i t i s h C o l u m b i a was c o n d u c t i n g a s t u d y a n d w o u l d be a p p r o a c h i n g them f o r p e r m i s s i o n . P e r m i s s i o n was o b t a i n e d a t t h e f i f t h h o s p i t a l t h r o u g h t h e n u r s i n g s u p e r v i s o r . T h i s h o s p i t a l , h o w e v e r , was n o t i n c l u d e d i n t h e s t u d y d u e t o t h e f a c t t h a t s h o r t l y a f t e r t h e f i r s t p a t i e n t h a d a n s w e r e d t h e f i r s t 25 s e t o f q u e s t i o n n a i r e s , a s t r i k e o f h o s p i t a l s t a f f s t a r t e d and a p i c k e t l i n e was s e t up o u t s i d e t h e h o s p i t a l . The S u b j e c t s The s u b j e c t s s e l e c t e d w e r e 21 men s u f f e r i n g f r o m m y o c a r d i a l i n f a r c t i o n . The c r i t e r i a f o r t h e s e l e c t i o n o f s u b j e c t s f o r t h e s t u d y w e r e : S u b j e c t s m u s t h a v e s u f f e r e d t h e i r f i r s t m y o c a r d i a l i n f a r c t i o n . Some w r i t e r s s a y t h a t t h e number o f o c c u r r e n c e s o f t h e i l l n e s s a f f e c t s t h e r a t e o f r e t u r n t o w o r k . S u b j e c t s m u s t h a v e s u f f e r e d no o t h e r m a j o r i l l n e s s w h i l e i n t h e h o s p i t a l o r d u r i n g t h e t i m e i n t e r v a l b e t w e e n when t h e f i r s t s e t o f q u e s t i o n n a i r e s w e r e a n s w e r e d a nd t h e l a s t s e t o f q u e s t i o n n a i r e s w e r e a n s w e r e d . S u b j e c t s m u s t b e w i l l i n g t o p a r t i c i p a t e i n t h e s t u d y . Two p o t e n t i a l s u b j e c t s w e r e a s k e d t o j o i n b u t b o t h r e f u s e d b e c a u s e t h e y f e l t t i r e d . T h ey w e r e n o t i n c l u d e d i n t h e s t u d y . S u b j e c t s must b e a b l e t o r e a d a n d w r i t e E n g l i s h . T h i s was a n e c e s s i t y b e c a u s e t h e s u b j e c t s h a d t o a n s w e r s e v e r a l q u e s t i o n n a i r e s . S u b j e c t s m u s t be 64 y e a r s o f age o r y o u n g e r . T h i s m i n i m i z e d t h e c o n f l i c t i n g f a c t o r o f r e t i r e m e n t , e s p e c i a l l y f o r p e o p l e o v e r 65 y e a r s who w e r e s t i l l w o r k i n g a t t h e t i m e o f a d m i s s i o n . S u b j e c t s m u s t h a v e b e e n e m p l o y e d f o r t h e s i x months p r e v i o u s t o a d m i s s i o n t o t h e h o s p i t a l . T h i s was t o make s u r e 26 t h a t o n l y t h o s e who w e r e w o r k i n g w e r e i n c l u d e d i n t h e s t u d y . T h r e e months i s t h e u s u a l p r o b a t i o n a r y p e r i o d f o r w o r k and i f a p e r s o n h a s w o r k e d f o r s i x m o n t h s , i t i s u s u a l l y an i n -d i c a t i o n t h a t he i n t e n d s t o s t a y o r t h a t t h e e m p l o y e r i n t e n d s t o k e e p h i m . I n i t i a l C o n t a c t W i t h t h e S u b j e c t s P a t i e n t s ' r e c o r d s w e r e r e v i e w e d t o d e t e r m i n e e l i g i -b i l i t y o f s u b j e c t s f o r t h e s t u d y . The e l i g i b l e s u b j e c t s w e r e t h e n a p p r o a c h e d by t h e i n v e s t i g a t o r a t a t i m e c o n v e n i e n t f o r b o t h t h e s u b j e c t s and t h e h o s p i t a l s t a f f . The i n v e s t i g a t o r i n t r o d u c e d h e r s e l f and s t a t e d t h a t s h e was a g r a d u a t e s t u d e n t a t t h e U n i v e r s i t y o f B r i t i s h C o l u m b i a c o n d u c t i n g a s t u d y o n f e e l i n g s and w o r k r e s u m p t i o n o f p a t i e n t s w i t h m y o c a r d i a l i n -f a r c t i o n . The q u e s t i o n n a i r e p r o c e d u r e was e x p l a i n e d t o e a c h s u b j e c t . He w o u l d be a s k e d t o a n s w e r : a) t h e S u b j e c t ' s P r o -f i l e Q u e s t i o n n a i r e o n c e w h i l e i n t h e h o s p i t a l ; b) two o t h e r s e t s o f q u e s t i o n n a i r e s ( N a v r a n Dy a n d D-I S c a l e ) t w i c e i n t h e h o s p i t a l and o n c e i n t h e i r home; and c) t h e Work R e s u m p t i o n Q u e s t i o n n a i r e o n c e i n t h e i r home. C o n f i d e n t i a l i t y was e x p l a i n e d and r e a s s u r a n c e was g i v e n t h a t t h e y c o u l d w i t h d r a w f r o m t h e s t u d y a t a n y t i m e t h e y s o w i s h e d . E a c h was t h e n a s k e d t o p a r -t i c i p a t e i n t h e s t u d y and s i g n t h e C o n s e n t t o P a r t i c i p a t e f o r m . The C o n s e n t t o P a r t i c i p a t e i s shown i n A p p e n d i x A. 27 I I . INSTRUMENTATION S e v e r a l i n s t r u m e n t s w e r e u s e d t o o b t a i n d a t a i n t h i s s t u d y . The S u b j e c t ' s P r o f i l e Q u e s t i o n n a i r e f o r u s e i n t h e h o s p i t a l a n d t h e Work R e s u m p t i o n Q u e s t i o n n a i r e f o r u s e i n t h e home, w e r e d e v e l o p e d . T h e s e w e r e d e s i g n e d f o l l o w i n g a r e v i e w o f t h e l i t e r a t u r e and w e r e i n t e n d e d t o o b t a i n i n f o r m a t i o n r e -l e v a n t t o t h e r e s e a r c h p r o b l e m . The N a v r a n Dy p o r t i o n o f t h e MMPI was u s e d t o m e a s u r e t h e l e v e l o f t r a i t d e p e n d e n c y and t h e D e p e n d e n c y S c a l e p o r t i o n o f t h e D e p e n d e n c y - I n d e p e n d e n c y S c a l e o f D e r d i a r i a n and c o l l e a g u e s was u s e d t o m e a s u r e t h e s t a t e d e p e n d e n c y . The i n s t r u m e n t s u s e d i n t h i s s t u d y a r e shown i n A p p e n d i x B. The q u e s t i o n n a i r e s a n s w e r e d i n t h e h o s p i t a l a n d i n t h e s u b j e c t ' s home t o o k b e t w e e n 20 a n d 45 m i n u t e s t o c o m p l e t e . To e n s u r e a n o n y m i t y , numbers w e r e u s e d t o i d e n t i f y d a t a r a t h e r t h a n t h e name o f t h e s u b j e c t s . S u b j e c t ' s P r o f i l e Q u e s t i o n n a i r e Two o f t h e q u e s t i o n s i n t h i s q u e s t i o n n a i r e w e r e i n -c l u d e d t o o b t a i n b a c k g r o u n d i n f o r m a t i o n . S u c h q u e s t i o n s c o n -c e r n e d s e x a n d m a r i t a l s t a t u s . Some o f t h e q u e s t i o n s w e r e u s e d t o o b t a i n d a t a t o e n s u r e t h a t t h e r e s p o n d e n t s met t h e c r i t e r i a o f t h e s t u d y . T h e s e q u e s t i o n s c o n c e r n e d a ge a n d e m p l o y m e n t . O t h e r q u e s t i o n s w e r e u s e d t o o b t a i n i n f o r m a t i o n a b o u t f a c t o r s m e n t i o n e d i n t h e l i t e r a t u r e a s b e i n g i m p l i c a t e d w i t h w o r k r e s u m p t i o n o f p a t i e n t s w i t h m y o c a r d i a l i n f a r c t i o n . T h e s e 28 w e r e c o n c e r n e d w i t h t h e k i n d a n d l e n g t h o f e m p l o y m e n t . O t h e r s w e r e u s e d t o g a t h e r d a t a t o s e r v e as a b a s i s f o r c o m p a r i s o n a f t e r t h e s t u d y . The l a t t e r q u e s t i o n c o n c e r n e d number o f h o u r s w o r k e d e a c h d a y b e f o r e t h e i l l n e s s . Work R e s u m p t i o n Q u e s t i o n n a i r e T h i s q u e s t i o n n a i r e was p r e p a r e d t o c o l l e c t d a t a o n t h e s u b j e c t ' s r e s u m p t i o n o r n o n - r e s u m p t i o n o f w o r k t h r e e m o n t h s a f t e r h i s d i s c h a r g e . Q u e s t i o n s a s k e d i n c l u d e d w h e t h e r he was b a c k t o w o r k , a n d r e a s o n s f o r n o t w o r k i n g i f he was n o t b a c k t o w o r k . Q u e s t i o n s a l s o i n c l u d e d amount o f t i m e l a p s e d b e t w e e n d i s c h a r g e a n d w o r k r e s u m p t i o n ; t h e k i n d o f j o b he h a d , and t h e number o f h o u r s he was w o r k i n g . The a n s w e r t o t h e l a s t t w o q u e s t i o n s w e r e n e c e s s a r y f o r c o m p a r i s o n w i t h t h e s u b j e c t ' s p r e v i o u s o c c u p a t i o n as t o t h e k i n d o f j o b a n d number o f h o u r s w o r k e d . D e p e n d e n c e / I n d e p e n d e n c e S c a l e The D-I S c a l e , a q u e s t i o n n a i r e d e v e l o p e d by D e r d i a r i a n , C l o u g h and W i t t i g , l i s t s e x a m p l e s o f t y p e s o f b e h a v i o u r w h i c h r e p r e s e n t t h e t e n c o m p o n e n t p a r t s o f d e p e n d e n c e / i n d e p e n d e n c e i d e n t i f i e d b y B e l l e r . 5 ^ B e h a v i o u r s u n d e r t h e d e p e n d e n t com-p o n e n t s a r e : s e e k s p h y s i c a l c o n t a c t , s e e k s p r o x i m i t y , s e e k s a t t e n t i o n , a nd s e e k s r e c o g n i t i o n , p r a i s e a n d a p p r o v a l . B e h a -v i o r s u n d e r t h e i n d e p e n d e n t c o m p o n e n t s a r e : t a k e s i n i t i a t i v e , o v e r c o m e s o b s t a c l e s , i s p e r s i s t e n t , s e e k s s a t i s f a c t i o n f r o m w o r k , a n d w a n t s t o do t h i n g s b y o n e s e l f . D e r d i a r i a n a nd a s s o -c i a t e s a d m i n i s t e r e d t h e q u e s t i o n n a i r e t o 25 p a t i e n t s f o r s u r g e r y . 29 U s i n g t h e P e a r s o r a P r o d u c t - M o m e n t C o r r e l a t i o n , t h e r e s u l t was t e s t e d f o r r e l i a b i l i t y . T he d e p e n d e n c e p o r t i o n h a s a r e l i a -b i l i t y o f r=.957 a n d t h e i n d e p e n d e n c e p o r t i o n h a s a r e l i a b i -l i t y o f r = . 9 2 7 . I n t h i s s t u d y , o n l y t h e d e p e n d e n t c o m p o n e n t s o f t h e q u e s t i o n n a i r e w i l l be u s e d . The s c a l e a s k s t h e s u b j e c t t o r a t e h i m s e l f on a s c a l e o f 1 t o 5, a c c o r d i n g t o t h e d e g r e e t h a t t h e s t a t e m e n t p r e -s e n t l y d e s c r i b e s h i s b e h a v i o u r . The mean s c o r e s o f t h e d e p e n -d e n t a n d i n d e p e n d e n t c o m p o n e n t s a r e c a l c u l a t e d . The v a l u e s , 1 t o 5, d i s t i n g u i s h b e t w e e n t h e n o n - d e p e n d e n t , s l i g h t l y d e -p e n d e n t , m o d e r a t e l y d e p e n d e n t , f a i r l y d e p e n d e n t a n d v e r y d e p e n d e n t p a t i e n t s . T h e y a r e 1, 2, 3, 4, a n d 5, r e s p e c t i v e l y . I t s c o n s t r u c t s s u p p o r t s t a t e d e p e n d e n c e . ^ 9 N a v r a n Dy P o r t i o n o f t h e MMPI The N a v r a n Dy c o n s t r u c t s s u p p o r t t r a i t d e p e n d e n c e . I t l i s t s e x a m p l e s o f d e p e n d e n t b e h a v i o u r s w h i c h t h e s u b j e c t i s a s k e d t o mark t r u e o r f a l s e a s a p p l i e d t o h i m . I n N a v r a n ' s s t u d y , 16 j u d g e s c h o s e t h e i t e m s f r o m o t h e r p r e - e x i s t i n g s c a l e s i n t h e MMPI w h i c h t h e y c o n s i d e r e d i n d i c a t i v e o f d e p e n d e n c e , a n d s p e c i f i e d t h e d i r e c t i o n i n w h i c h t h e d e p e n d e n t p e r s o n w o u l d r e s p o n d . I n t e r n a l c o n s i s t e n c y was d e t e r m i n e d f o r 2 s a m p l e s o f 50 p a t i e n t s , a n d c r o s s v a l i d a t i o n was d o n e b e t w e e n t h e 2 s a m p l e p o p u l a t i o n s . The f i n a l T - s c o r e s as g i v e n i n t h e MMPI h a n d b o o k w e r e r e c o r d e d f o r e a c h raw s c o r e . U s i n g t h e K u d e r - R i c h a r d s o n F o r m u l a 2 0 , t h e r e l i a b i l i t y f o r 100 p a t i e n t s i s . 91. 30 I I I . PRE-TEST The i n s t r u m e n t s d e v e l o p e d w e r e r e v i e w e d b y a n u r s e -e d u c a t o r a n d a n i n t e n s i v e c a r e n u r s e . A l l t h e t o o l s u s e d w e r e c r i t i c i z e d i n a r e s e a r c h c l a s s o f 13 g r a d u a t e s t u d e n t s a n d 2 r e s e a r c h i n s t r u c t o r s . The S u b j e c t P r o f i l e Q u e s t i o n n a i r e a n d t h e D-I S c a l e w e r e p r e - t e s t e d o n 11 s u b j e c t s i n one o f t h e h o s p i t a l s w h e r e t h e s t u d y was f i n a l l y c o n d u c t e d . A f e w f u r t h e r a d j u s t m e n t s w e r e made on t h e S u b j e c t P r o f i l e Q u e s t i o n n a i r e t o i m p r o v e c l a r i t y . The Work R e s u m p t i o n Q u e s t i o n n a i r e was p r e - t e s t e d on one p a t i e n t a n d a m i n o r a d j u s t m e n t was d o n e o n i t t o r e d u c e a m b i g u i t y . The q u e s t i o n n a i r e was p r e - t e s t e d on one p a t i e n t o n l y as t h e f o u r q u e s t i o n s i n c l u d e d i n i t w e r e t a k e n f r o m t h e S u b j e c t P r o f i l e Q u e s t i o n n a i r e . The S u b j e c t P r o f i l e Q u e s t i o n -n a i r e was a l r e a d y p r e - t e s t e d on 11 s u b j e c t s . The p r e - t e s t h e l p e d t h e i n v e s t i g a t o r g a i n p r o f i c i e n c y i n a d m i n i s t e r i n g t h e q u e s t i o n n a i r e s . I t a l s o h e l p e d t o i m p r o v e t h e c l a r i t y o f t h e q u e s t i o n n a i r e s . I V . ADMINISTRATION OF THE QUESTIONNAIRES The f i r s t s e t o f q u e s t i o n n a i r e s w e r e a n s w e r e d on t h e 6 t h t o 1 0 t h d a y o f s t a y i n t h e h o s p i t a l P o s t C o r o n a r y U n i t . The q u e s t i o n n a i r e s w e r e a n s w e r e d i n t h e m o r n i n g o r a f t e r n o o n a f t e r t h e s u b j e c t s ' one h o u r n a p u n l e s s t h e s u b j e c t was o t h e r -w i s e e n g a g e d . The S u b j e c t P r o f i l e Q u e s t i o n n a i r e was a d m i n i s -t e r e d f i r s t . The r e s e a r c h e r t h e n e x p l a i n e d t o t h e s u b j e c t 31 t h e u s e o f s e l f - r e p o r t i n s t r u m e n t s , t h e N a v r a n Dy and t h e D-I S c a l e . The s u b j e c t was t h e n t o l d t h a t he was f r e e t o a s k t h e i n v e s t i g a t o r a n y q u e s t i o n s r e g a r d i n g a n y p a r t o f t h e q u e s t i o n -n a i r e s . Q u e s t i o n s a s k e d w e r e d i s c u s s e d c a r e f u l l y . The i n -v e s t i g a t o r c o l l e c t e d t h e a n s w e r e d q u e s t i o n n a i r e s when t h e s u b -j e c t was f i n i s h e d . The s u b j e c t s a n s w e r e d t h e s e c o n d s e t o f q u e s t i o n n a i r e s d u r i n g t h e i r l a s t week i n t h e P o s t C o r o n a r y U n i t . The same p r o c e d u r e a n d e x p l a n a t i o n was d o n e e x c e p t t h i s t i m e t h e S u b -j e c t ' s P r o f i l e Q u e s t i o n n a i r e was n o t i n c l u d e d . A f t e r t h e q u e s t i o n n a i r e s w e r e a n s w e r e d , t h e s u b j e c t was t o l d t h a t t h e i n v e s t i g a t o r w o u l d t e l e p h o n e h i m a b o u t t h r e e m onths a f t e r d i s -c h a r g e t o make an a p p o i n t m e n t t o t a k e t h e f i n a l s e t o f q u e s t i o n -n a i r e s t o h i s home. B e c a u s e some p a t i e n t s w e r e d i s c h a r g e d o n t h e i r 1 s t t o 5 t h d a y o f s t a y i n t h e P o s t C o r o n a r y U n i t , t h e s e p a t i e n t s a n s w e r e d t h e q u e s t i o n n a i r e s o n l y o n c e w h i l e i n t h e h o s p i t a l . F o u r s u b j e c t s d i d n o t c o m p l e t e t h e s e c o n d q u e s t i o n -n a i r e s . The t h i r d s e t o f q u e s t i o n n a i r e s , N a v r a n Dy a n d Depen-d e n c y S c a l e o f t h e D-I S c a l e , w e r e a n s w e r e d i n t h e s u b j e c t ' s home a b o u t t h r e e m onths a f t e r d i s c h a r g e . B e f o r e he a n s w e r e d t h em, he was a s k e d t o a n s w e r t h e Work R e s u m p t i o n Q u e s t i o n n a i r e . He was t h e n g i v e n t h e two s e t s o f q u e s t i o n n a i r e s w i t h t h e same i n s t r u c t i o n a s w i t h t h e p r e v i o u s t i m e s . A g a i n , a n y q u e s t i o n s a s k e d b y t h e s u b j e c t w e r e d i s c u s s e d . T h i s t i m e i n q u i r i e s o f s p o u s e w e r e a l s o d i s c u s s e d . The s u b j e c t was t h e n t h a n k e d f o r 32 h i s p a r t i c i p a t i o n a n d t h o s e w e r e e x p r e s s e d i n t e r e s t i n k n o w i n g t h e r e s u l t s o f t h e s t u d y w e r e n o t e d by t h e i n v e s t i g a t o r . T h r e e s u b j e c t s w e r e n o t a b l e t o a n s w e r t h e t h i r d s e t o f q u e s -t i o n n a i r e s : t w o , who a r e b o t h b a c k t o w o r k , r e f u s e d t o a n s w e r f o r t h e t h i r d t i m e ; a n d o n e d i e d o f a n o t h e r h e a r t a t t a c k . T a b l e 1 i l l u s t r a t e s t h e s c h e d u l e o f a d m i n i s t r a t i o n o f q u e s t i o n n a i r e s . TABLE I SCHEDULE OF ADMINISTRATION OF QUESTIONNAIRES . 6 t h - 1 0 t h d a y a t PCU Week o f D i s c h a r g e T h r e e M o n t h s A f t e r D i s c h a r g e S u b j e c t P r o f i l e N a v r a n Dy S c a l e Work R e s u m p t i o n w h i c h i n c l u d e s Work D-I S c a l e P r o f i l e P r o f i l e N a v r a n Dy S c a l e N a v r a n Dy S c a l e D-I S c a l e D-I S c a l e V. S T A T I S T I C A L ANALYSIS T t e s t was u s e d t o d e t e r m i n e e f f e c t s o f v a r i a b l e s , h o s p i t a l d i f f e r e n c e s a n d h y p o t h e s i s 1. H y p o t h e s e s 2 and 3 w e r e t e s t e d b y t h e T w o - F a c t o r A n a l y s i s o f V a r i a n c e . 33 V I . SUMMARY T h i s c h a p t e r d e s c r i b e s t h e m e t h o d o l o g y u s e d i n t h i s s t u d y , t h e q u e s t i o n n a i r e s u s e d t o g a t h e r i n f o r m a t i o n r e q u i r e d f o r t h e s t u d y , t h e s e l e c t i o n o f t h e s u b j e c t s , t h e a d m i n i s -t r a t i o n o f q u e s t i o n n a i r e s , and e n u m e r a t e s t h e s t a t i s t i c a l a n a l y s i s o f t h e s t u d y . 34 CHAPTER IV ANALYSIS OF THE DATA Age, o c c u p a t i o n , and number o f days i n t h e C o r o n a r y Care U n i t and t h e P o s t C o r o n a r y U n i t o f t h e s t u d y p o p u l a t i o n a r e d e s c r i b e d and shown i n f r e q u e n c y t a b l e s and d i s t r i b u t i o n s . The d i f f e r e n c e s o f t h e h o s p i t a l f a c t o r s a r e a s s e s s e d and d e s -c r i b e d i n t a b l e s and t a b u l a t i o n , and t h e p r e s e n c e o f low and h i g h t r a i t dependency o f t h e s t u d y p o p u l a t i o n i s a s s e s s e d . F u r t h e r a n a l y s i s o f t h e d a t a i s c a r r i e d o u t t o t e s t t h e t h r e e h y p o t h e s e s . I TESTING HOSPITAL DIFFERENCE The s t u d y p o p u l a t i o n c o n s i s t e d o f 21 p a t i e n t s w i t h m y o c a r d i a l i n f a r c t i o n a d m i t t e d a t two s e l e c t e d h o s p i t a l s d u r i n g t h e months o f December t o A u g u s t . F o u r t e e n s u b j e c t s a r e f r o m H o s p i t a l A and 7 a r e f r o m H o s p i t a l B. Because t h e two h o s p i t a l s a r e l o c a t e d i n d i f f e r e n t m u n i c i p a l i t i e s c a t e r -i n g t o d i f f e r e n t p o p u l a t i o n s and w i t h d i f f e r e n t s e t s o f s p e c i a l i s t s a t t e n d i n g t h e p a t i e n t s , i t was d e c i d e d t h a t sub-j e c t s f r om t h e two h o s p i t a l s be t e s t e d f o r any d i f f e r e n c e s . To do t h i s , T t e s t was done on t h e s u b j e c t s ' age, number o f days i n t h e C o r o n a r y Care U n i t , number o f days i n t h e P o s t C o r o n a r y U n i t and t h e i r f i r s t Navran Dy s c o r e . A t l e v e l 0.05, o n l y t h e number o f days i n t h e Cor o n a r y Care U n i t showed s i g n i f i c a n t d i f f e r e n c e between t h e s u b j e c t s from t h e two h o s p i t a l s . 35 AGE I n H o s p i t a l A, t h e ages o f t h e s u b j e c t s r a n g e d f r o m 31 t o 64 y e a r s , w h i l e i n H o s p i t a l B t h e s u b j e c t s * ages r a n g e d from 41 t o 60 y e a r s . T a b l e 2 i l l u s t r a t e s t h e f r e q u e n c y d i s -t r i b u t i o n o f t h e s t u d y p o p u l a t i o n f rom t h e two h o s p i t a l s by age. TABLE 2 FREQUENCY DISTRIBUTION OF THE STUDY POPULATION FROM TWO HOSPITALS BY AGE  HOSPITAL A HOSPITAL B AGE FREQUENCY FREQUENCY 30 o r under 0 0 31-40 1 0 41-50 5 2 51-60 7 5 60-64 _1 0 TOTAL 14 7 Mean o f H o s p i t a l A = 3.57 Mean o f H o s p i t a l B = 3.71 T = .45 P > 0.05 NUMBER OF DAYS I N THE CORONARY CARE UNIT I n H o s p i t a l A, t h e s u b j e c t s s t a y e d i n t h e C o r o n a r y C a r e U n i t f r o m 2 t o 7 days w i t h a mean o f 4.07 d a y s . I n H o s p i t a l B, the s u b j e c t s s t a y e d i n t h e C o r o n a r y C a r e U n i t f r o m 3 t o 9 days w i t h a mean o f 5.71 d a y s . T a b l e 3 i l l u s t r a t e s t h e f r e q u e n c y d i s t r i b u t i o n o f t h e s t u d y p o p u l a t i o n f r o m two h o s p i t a l s b y t h e number o f days i n t h e C o r o n a r y C a r e U n i t . A t 0.05 l e v e l t h e number o f days t h e s u b j e c t s f rom H o s p i t a l A s p e n t i n t h e C o r o n a r y Care U n i t i s s i g n i f i c a n t l y l e s s than t h a t o f t h e s u b j e c t s f r o m H o s p i t a l B. 36 TABLE 3 FREQUENCY D I S T R I B U T I O N OF THE STUDY POPULATION FROM TWO HOSPITALS BY THE NUMBER OF CCU DAYS HOSPITAL A HOSPITAL B NUMBER OF DAYS FREQUENCY FREQUENCY 2 1 0 3 3 1 4 6 2 5 3 1 6 0 1 7 1 0 8 0 0 9 0 2 TOTAL 14 7 Mean o f H o s p i t a l A = 4.07 Mean o f H o s p i t a l B = 5.71 T = 2.10 p< 0.05 NUMBER OF DAYS I N THE POST CORONARY UNIT I n H o s p i t a l A, t h e s u b j e c t s s t a y e d i n t h e P o s t C o r o n a r y U n i t f r o m 4 t o 19 d a y s w i t h a mean o f 1 2 . 8 6 . I n H o s p i t a l B, t h e s u b j e c t s s t a y e d i n t h e u n i t f r o m 1 t o 18 d a y s w i t h a mean o f 9.14. T a b l e 4 i l l u s t r a t e s t h e f r e -q u e n c y d i s t r i b u t i o n o f t h e s t u d y p o p u l a t i o n f r o m t h e t w o h o s p i t a l s b y t h e number o f d a y s i n t h e P o s t C o r o n a r y U n i t . 3 7 TABLE 4 FREQUENCY D I S T R I B U T I O N OF THE STUDY POPULATION FROM TWO HOSPITALS BY THE NUMBER OF PCU DAYS NUMBER OF DAYS HOSPITAL A FREQUENCY H O S P I T A L B FREQUENCY 1-7 8-14 15-21 TOTAL 2 7 _5 14 2 4 1 7 Mean o f H o s p i t a l A = 12.86 Mean o f H o s p i t a l B = 9.4 T = 1.69 P > 0.05 F I R S T NAVRAN DY SCORES The f i r s t N a v r a n Dy S c o r e s w e r e u s e d b e c a u s e i t i s t h e o n l y t e s t i n g o c c a s i o n when e v e r y s u b j e c t i n c l u d e d i n t h e s t u d y was a b l e t o a n s w e r . I n H o s p i t a l A f t h e s c o r e r a n g e d f r o m 6 t o 23 w i t h a mean o f 17.57, w h i l e i n H o s p i t a l B, t h e s c o r e r a n g e d f r o m 5 t o 24 w i t h a mean o f 16.29. T a b l e 5 i l l u s t r a t e s t h e f r e q u e n c y d i s t r i b u t i o n o f t h e s t u d y p o p u l a -t i o n f r o m t w o h o s p i t a l s b y t h e N a v r a n Dy S c o r e . 38 TABLE 5 FREQUENCY D I S T R I B U T I O N OF THE STUDY POPULATION FROM TWO HOSPITALS BY THE NAVRAN DY SCORES HOSPITAL A HOSP I T A L B. SCORES FREQUENCY FREQUENCY 4-6 1 1 7-9 0 0 10-12 1 1 13-15 4 1 16-18 2 1 19-21 2 1 22-24 3 2 25-27 1 0 TOTAL 14" 7 Mean o f H o s p i t a l A = 17.57 Mean o f H o s p i t a l B = 16.29 T = .08 P > 0.05 I I T E S T I NG V A R I A B L E S D u r i n g t h e d a t a a n a l y s i s , s e v e r a l v a r i a b l e s w e r e i n c l u d e d t o d e t e r m i n e t h e i r e f f e c t s o n t h e s u b j e c t ' s w o r k r e s u m p t i o n . A ge was i n c l u d e d b e c a u s e some o f t h e l i t e r a t u r e c l a i m s t h a t i t a f f e c t s w o r k r e s u m p t i o n o f p a t i e n t s w i t h myo-61 62 c a r d i a l i n f a r c t i o n . ' The number o f d a y s i n t h e C o r o n a r y C a r e U n i t a n d P o s t C o r o n a r y U n i t w e r e a l s o t e s t e d t o make s u r e t h a t t h e y do n o t h a v e a n y b e a r i n g o n t h e r e s u l t o f t h e a n a l y -s i s o f t h e d a t a . W o r k i n g a t 0.05 l e v e l o f s i g n i f i c a n c e , T t e s t d i d n o t show a n y s i g n i f i c a n t f i n d i n g s among t h e v a r i a b l e s . AGE Th e a g e o f t h e e m p l o y e d g r o u p r a n g e d f r o m 41 t o 60 y e a r s , w h i l e t h e age o f t h e u n e m p l o y e d g r o u p r a n g e d f r o m 31 39 t o 64 y e a r s . T a b l e 6 i l l u s t r a t e s t h e d i s t r i b u t i o n o f t h e employed and unemployed s t u d y p o p u l a t i o n by age. TABLE 6 FREQUENCY DISTRIBUTION OF THE EMPLOYED AND UNEMPLOYED STUDY POPULATION BY AGE AGE EMPLOYED UNEMPLOYED FREQUENCY FREQUENCY 31-40 41^50 51-60 61-64 TOTAL 0 i 5 2 3 9 0 _ i ~8 13 Mean o f Employed = 3 . 3 8 Mean o f Unemployed = 3 . 7 7 T = 1.34 P > 0.05 MTTMnFR OF DAYS IN THE CORONARY CARE UNIT The number o f days o f t h e employed g r o u p i n t h e C o r o n a r y Care U n i t r a n g e d f r o m 3 t o 9 days w i t h a mean o f 4.75 days w h i l e t h e number o f days o f t h e unemployed group i n the C o r o n a r y C a r e U n i t r a n g e d f r o m 2 t o 9 days w i t h a mean o f 4.54 d a y s . T a b l e 7 i l l u s t r a t e s t h e f r e q u e n c y d i s -t r i b u t i o n o f t h e employed and unemployed s t u d y p o p u l a t i o n by t h e number o f days i n t h e C o r o n a r y C a r e U n i t . 40 TABLE 7 FREQUENCY DISTRIBUTION OF THE EMPLOYED AND UNEMPLOYED STUDY POPULATION BY THE NUMBER OF DAYS IN CCU EMPLOYED UNEMPLOYED NUMBER OF DAYS FREQUENCY FREQUENCY 2 0 : 1 3 1 3 4 5 3 5 0 4 6 1 0 7 1 1 8 0 0 9 • 0 1 TOTAL 8 13 Mean o f Employed = 4.75 Mean o f Unemployed = 4.54 T = .25 P > 0.05 •NUMBER OF DAYS IN THE POST CORONARY UNIT The number o f days o f t h e employed g r o u p i n t h e P o s t C o r o n a r y U n i t r a n g e d f r o m 10 t o 19 w i t h a mean o f 14 days w h i l e t h e unemployed group r a n g e d from 1 t o 18 d a y s w i t h a mean o f 10.15 d a y s . T a b l e 8 i l l u s t r a t e s t h e f r e q u e n c y d i s -t r i b u t i o n o f t h e employed and unemployed s t u d y p o p u l a t i o n by t h e number o f days i n t h e P o s t C o r o n a r y U n i t . 41 TABLE 8 FREQUENCY D I S T R I B U T I O N OF THE EMPLOYED AND UNEMPLOYED STUDY POPULATION BY THE NUMBER OF DAYS I N PCU EMPLOYED UNEMPLOYED NUMBER OF DAYS FREQUENCY FREQUENCY 1-3 0 1 4-6 0 3 7-9 0 2 10-12 2 2 13-15 4 3 16-18 1 2 19-21 1 0 TOTAL 8 13 Mean o f E m p l o y e d = 14 Mean o f U n e m p l o y e d = 10.15 T = 1.82 P ;> 0.05 I I I T E S T I N G THE HYPOTHESES Mann W h i t n e y U T e s t , a n o n p a r a m e t r i c t e s t , was u s e d t o a s s e s s t h e r e l a t i o n s h i p o f e m p l o y m e n t t o t r a i t d e p e n d e n c e a s m e a s u r e d b y t h e N a v r a n Dy S c a l e . T h e e m p l o y e d g r o u p h a s s c o r e s r a n g i n g f r o m 5 t o 26 w i t h a mean o f 17 w h i l e t h e u n -e m p l o y e d g r o u p h a s s c o r e s r a n g i n g f r o m 11 t o 23 w i t h a mean o f 17.23. W o r k i n g a t 0.05 l e v e l o f s i g n i f i c a n c e , no s i g n i -f i c a n t d i f f e r e n c e was f o u n d . T a b l e 9 i l l u s t r a t e s t h e f r e -q u e n c y d i s t r i b u t i o n o f t h e e m p l o y e d a n d u n e m p l o y e d s t u d y p o p u l a t i o n b y t h e i r N a v r a n Dy s c o r e s . 4 2 TABLE 9 FREQUENCY DISTRIBUTION OF THE EMPLOYED AND UNEMPLOYED STUDY POPULATION BY THEIR NAVRAN DY SCORES  SCORES EMPLOYED FREQUENCY UNEMPLOYED FREQUENCY 0 - 5 6 - 1 0 1 1 - 1 5 1 6 - 2 0 2 1 - 2 5 2 6 - 3 0 TOTAL 1 0 4 0 2 J L 8 0 1 3 5 4 0 1 3 M e d i a n = 1 7 . 5 Mann W h i t n e y U S t a t i s t i c s = . 2 5 P ^> 0 . 0 5 Among t h e 2 1 s u b j e c t s who a n s w e r e d t h e q u e s t i o n n a i r e s , o n l y 1 4 a n s w e r e d t h e q u e s t i o n n a i r e s t h r e e t i m e s , 4 a n s w e r e d t h e q u e s t i o n n a i r e s o n t h e f i r s t and t h i r d o c c a s i o n s , a n d 3 a n s w e r e d t h e q u e s t i o n n a i r e s on t h e f i r s t a n d s e c o n d o c c a s i o n s . T h i s was due t o s e v e r a l f a c t o r s . Some s u b j e c t s w e n t home e a r l i e r t h a n e x p e c t e d t h u s t h e r e s e a r c h e r was n o t a b l e t o l e t them a n s w e r t h e s e c o n d q u e s t i o n n a i r e s , a n d o t h e r s r e f u s e d t o a n swer t h e t h i r d q u e s t i o n n a i r e . One d i e d b e t w e e n t h e s e c o n d and t h i r d t e s t i n g o c c a s i o n s . O n l y t h o s e who a n s w e r e d t h e q u e s t i o n n a i r e s t h r e e t i m e s and t h o s e who a n s w e r e d t h e t h i r d q u e s t i o n n a i r e s o n t h e f i r s t a n d t h i r d o c c a s i o n s w e r e i n c l u d e d i n t h e d a t a a n a l y s i s t o t e s t h y p o t h e s e s 1 and 2 . S i x o f t h e s e 1 8 s u b j e c t s a r e b a c k t o work w h i l e 1 2 a r e s t i l l r e s t i n g . 43 Among the 12 who a r e n o t back t o work, o n l y 1 was p r e v e n t e d from d o i n g so because o f a n o t h e r h e a r t a t t a c k . Three were n o t back t o work because o f d o c t o r ' s a d v i c e . One o f t h e s e 3 had m i l d i s c h e m i c symptoms such as o c c a s i o n a l a n g i n a , one had no symptoms and e x p e c t e d t o go back t o work one week a f t e r t h e l a s t s e t o f q u e s t i o n n a i r e s was answered, w h i l e one d i d n o t know when h i s d o c t o r would l e t him go back t o work. Two o f t h e s u b j e c t s went f o r angiogram a week a f t e r t h e l a s t t e s t i n g o c c a s i o n . They had no p a i n , b u t t h e i r s t r e s s t e s t d i d not show up t o p a r so angiogram was used f o r f u r t h e r v e r i f i c a t i o n . Two d i d n o t go back t o work because t h e y f e l t t h e y needed more r e s t , and one f e l t he was n o t p r e p a r e d t o go back t o work y e t . He had n o t had any p a i n s i n c e d i s c h a r g e . Of t h e 6 who r e t u r n e d t o work, 2 d i d n o t r e t u r n f u l l t i m e t o t h e i r f o r m e r j o b s . They were, however, i n c r e a s i n g t h e i r f o u r - h o u r days t o f u l l t i m e work g r a d u a l l y . D u r i n g t h e f i r s t t e s t i n g o c c a s i o n , a t t h e P o s t C o r o -n a r y U n i t , t h e s t a t e dependency s c o r e s measured by the D-I S c a l e ranged from 1.33 t o 3.06 w i t h a mean o f 2.06, w h i l e d u r i n g t h e t h i r d t e s t i n g o c c a s i o n , t h e s c o r e s ranged from 1.16 t o 2.52 w i t h a mean o f 1.97. T a b l e 10 i l l u s t r a t e s t h e f r e q u e n c y d i s t r i b u t i o n o f t h e s t u d y p o p u l a t i o n by t h e i r de-pendency s c o r e s d u r i n g f i r s t and t h i r d t e s t i n g o c c a s i o n s . 44 TABLE 10 FREQUENCY DISTRIBUTION OF THE STUDY POPULATION BY THEIR STATE DEPENDENCY SCORES DURING F I R S T AND THIRD TESTING OCCASIONS F I R S T OCCASION THIRD OCCASION SCORES FREQUENCY FREQUENCY 1.00-1.25 0 2 1.26-1.50 2 1 1.5.1-1.75 4 4 1.76-2.00 2 1 2.01-2.25 3 5 2.26-2.50 5 2 2.51-2.75 1 3 2.76-3.00 0 0 3.01-3.25 1 0 TOTAL 18 18 Mean o f f i r s t t e s t i n g o c c a s i o n = 2.00 Mean o f t h i r d t e s t i n g o c c a s i o n = 1.97 The s t a t e d e p e n d e n c y s c o r e s o f t h e e m p l o y e d g r o u p r a n g e d f r o m 1.33 t o 2.26 w i t h a mean o f 1.38 d u r i n g t h e f i r s t t e s t i n g o c c a s i o n , w h i l e t h e i r s c o r e s r a n g e d f r o m 1.06 t o 2.20 w i t h a mean o f 1.78 d u r i n g t h e t h i r d t e s t i n g o c c a s i o n . The . s t a t e d e p e n d e n c y s c o r e s o f t h e u n e m p l o y e d g r o u p r a n g e d f r o m 1.69 t o 3.06 w i t h a mean o f 2.15 d u r i n g t h e f i r s t t e s t i n g o c c a s i o n , w h i l e t h e i r s c o r e s r a n g e d f r o m 1.16 t o 2.52 w i t h a mean o f 2.06 d u r i n g t h e t h i r d t e s t i n g o c c a s i o n . T a b l e 11 i l l u s t r a t e s t h e f r e q u e n c y d i s t r i b u t i o n o f t h e e m p l o y e d a nd u n e m p l o y e d s t u d y p o p u l a t i o n by t h e i r s t a t e d e p e n d e n c y s c o r e s d u r i n g t h e f i r s t a n d t h i r d t e s t i n g o c c a s i o n s . 45 TABLE 11 FREQUENCY DISTRIBUTION OF THE EMPLOYED AND UNEMPLOYED STUDY POPULATION BY THEIR STATE DEPENDENCY SCORES ^ DURING F I R S T AND THIRD TESTING OCCASIONS EMPLOYED UNEMPLOYED SCORES FREQUENCY FREQUENCY F I R S T THIRD F I R S T THIRD 1.00-1. 25 0 1 0 1 1.26-1. 50 1 1 1 0 1.51-1. 75 2 1 2 3 1.76-2. 00 0 0 2 1 2.01-2. 25 1 3 2 2 2.26-2. 50 2 0 3 2 2.51-2. 75 0 0 1 3 2.76-3. 00 0 0 0 0 3.01-3. 25 0 0 1 0 TOTAL 6 6 12 12 Means o f E m p l o y e d G r o u p F i r s t T e s t i n g O c c a s i o n Low T r a i t = 1.88 H i g h T r a i t = 1.97 T h i r d T e s t i n g O c c a s i o n Low T r a i t = 1.78 H i g h T r a i t = 1.97 Means o f U n e m p l o y e d G r o u p F i r s t T e s t i n g O c c a s i o n Low T r a i t = 2.03 H i g h T r a i t = 2 . 2 3 T h i r d T e s t i n g O c c a s i o n Low T r a i t = 1.89 H i g h T r a i t = 2.2 3 U s i n g t h e T w o - F a c t o r A n a l y s i s o f V a r i a n c e , t h e r e was. no s t a t i s t i c a l s i g n i f i c a n c e i n t h e c h a n g e s o f t h e s t a t e d e -p e n d e n c y s c o r e s o f t h e e m p l o y e d a n d u n e m p l o y e d g r o u p s a l o n g t h e c o n v a l e s c e n c e t o e m p l o y m e n t p e r i o d c o n t i n u u m . To t e s t h y p o t h e s i s 3, t h e s t u d y p o p u l a t i o n v/as d i v i -d e d i n t o h i g h a n d l o w t r a i t g r o u p s . The t r a i t d e p e n d e n c y s c o r e s r a n g e d f r o m 5 t o 26 d u r i n g t h e f i r s t t e s t i n g o c c a s i o n and 5 t o 41 d u r i n g t h e t h i r d t e s t i n g o c c a s i o n . T h o s e a b o v e t h e m e d i a n s c o r e o f 1 6 , a r e c o n s i d e r e d h i g h t r a i t and t h o s e 16 a nd b e l o w a r e c o n s i d e r e d l o w t r a i t . T h e r e a r e 10 l o w 46 t r a i t s u b j e c t s a n d 8 h i g h t r a i t s u b j e c t s . The s t a t e d e p e n d e n c y s c o r e s o f t h e l o w t r a i t s u b -j e c t s r a n g e d f r o m 1.61 to. 2.55 w i t h a mean o f 1.95 d u r i n g t h e f i r s t t e s t i n g o c c a s i o n , w h i l e t h e i r s c o r e s r a n g e d f r o m 1.0 6 t o 2.48 w i t h a mean o f 1.81 d u r i n g t h e t h i r d t e s t i n g o c c a s i o n . The s t a t e d e p e n d e n c y s c o r e s o f t h e h i g h t r a i t s u b j e c t s r a n g e d f r o m 1.68 t o 3.06 w i t h a mean o f 2.2 d u r i n g t h e f i r s t t e s t i n g o c c a s i o n w h i l e t h e i r s c o r e s r a n g e d f r o m 1.55 t o 2.71 w i t h a mean o f 2.17 d u r i n g t h e t h i r d t e s t i n g o c c a s i o n . T a b l e 12 i l l u s t r a t e s t h e f r e q u e n c y d i s t r i b u t i o n o f t h e l o w and h i g h t r a i t g r o u p s b y t h e i r s t a t e d e p e n d e n c y s c o r e s d u r i n g t h e 2 t e s t i n g o c c a s i o n s . TABLE 12 FREQUENCY DISTRIBUTION OF THE LOW AND HIGH TRAIT STUDY POPULATION BY THEIR STATE DEPENDENCY SCORES DURING F I R S T AND THIRD TESTING OCCASIONS LOV7 T R A I T HIGH TRAIT SCORES FREQUENCY FREQUENCY F I R S T THIRD F I R S T THIRD 1.00-1.25 0 2 0 0 1.26-1.50 2 1 0 0 1.51-1.75 2 2 2 3 1.76-2.00 1 ' 0 1 1 2.01-2.25 2 3 1 2 2.26-2.50 2 2 3 0 2.51-2.75 1 0 0 2 2.76-3.00 0 0 0 0 3.01-3.25 0 0 1 0 TOTAL 10" 10 8 8 47 Means o f S t a t e D e p e n d e n c y S c o r e s Low T r a i t F i r s t T e s t i n g O c c a s i o n = 1.95 T h i r d T e s t i n g O c c a s i o n =1.8 H i g h T r a i t F i r s t T e s t i n g O c c a s i o n = 2.2 T h i r d T e s t i n g O c c a s i o n = 2.17 U s i n g t h e T w o - F a c t o r A n a l y s i s o f V a r i a n c e , no s t a t i s t i c a l s i g n i f i c a n c e was f o u n d i n t h e c h a n g e s o f t h e s t a t e d e p e n d e n c y o f t h e l o w t r a i t and h i g h t r a i t d e p e n d e n c y g r o u p s a l o n g t h e c o n v a l e s c e n c e t o e m p l o y m e n t p e r i o d c o n t i n u u m . 48 CHAPTER V SUMMARY, CONCLUSIONS AND RECOMMENDATIONS I SUMMARY T h i s s t u d y i n v o l v e s a n i n v e s t i g a t i o n o f t h e r e l a t i o n -s h i p b e t w e e n d e p e n d e n c y and work r e s u m p t i o n o f p a t i e n t s w i t h m y o c a r d i a l i n f a r c t i o n . I n t h e p r o c e s s o f s t u d y i n g t h i s p r o b -lem, i n f o r m a t i o n c o n c e r n i n g t h e d i f f e r e n t l e v e l s o f d e p e n d e n c y d u r i n g t h e c o n v a l e s c e n c e t h r o u g h employment c o n t i n u u m was g a t h e r e d . The p u r p o s e s o f t h e s t u d y a r e t o add t o t h e body o f k n o w l e d g e c o n c e r n i n g t h e c o n c e p t o f d e p e n d e n c y and t o make n u r s e s and o t h e r members o f t h e h e a l t h team aware o f t h e i m -p l i c a t i o n s o f d e p e n d e n c y b e h a v i o u r i n t h e p r o c e s s o f r e s u m i n g n o r m a l f u n c t i o n o f p a t i e n t s v / i t h m y o c a r d i a l i n f a r c t i o n . I t s l o n g r a n g e p u r p o s e i s t o i n c r e a s e t h e s e n s e o f w e l l - b e i n g and a c h i e v i n g o f t h e p a t i e n t w i t h m y o c a r d i a l i n f a r c t i o n by h e l p i n g h i m resume h i s p r o d u c t i v e r o l e , b o t h t h r o u g h t h e h e l p o f mem-b e r s o f t h e h e a l t h team a n d members o f h i s f a m i l y . The s t u d y was p l a n n e d t o t e s t t h e f o l l o w i n g h y p o t h e s e s : 1. The e m p l o y e d p a t i e n t s w i t h m y o c a r d i a l i n f a r c t i o n w i l l show l o w e r d e p e n d e n c y r a t i n g s t h a n t h e u n e m p l o y e d p a t i e n t s i n t h e N a v r a n Dy S c a l e . 2. The e m p l o y e d p a t i e n t s w i t h m y o c a r d i a l i n f a r c t i o n w i l l show p r o g r e s s i v e d e c r e a s e i n t h e D-I S c a l e d e p e n d e n c y r a t i n g s a l o n g t h e c o n v a l e s c e n c e t o employment p e r i o d c o n t i n u u m , w h i l e t h e u n e m p l o y e d p a t i e n t s w i t h m y o c a r d i a l i n f a r c t i o n w i l l m a i n t a i n a c o n s t a n t l e v e l o f d e p e n d e n c y r a t i n g s i n t h e D-I S c a l e a l o n g t h e c o n v a l e s c e n c e t o em-p l o y m e n t p e r i o d c o n t i n u u m . 3. Low t r a i t d e p e n d e n t s w i t h m y o c a r d i a l i n f a r c t i o n w i l l show p r o g r e s s i v e d e c r e a s e i n t h e D-I S c a l e d e p e n d e n c y r a t i n g s a l o n g t h e c o n v a l e s c e n c e t o employment p e r i o d c o n t i n u u m , w h i l e h i g h t r a i t d e p e n d e n t p a t i e n t s w i t h myo-c a r d i a l i n f a r c t i o n w i l l c o n t i n u e t o show s t e a d y d e p e n d e n c y 49 ratings i n the D-I Scale along the convalescence to employment period continuum. A review of the l i t e r a t u r e presented, i n 3 parts, relevant theories and research pertinent to work resumption of patients with myocardial i n f a r c t i o n and dependency. The f i r s t part showed the writer's concept of dependence developed as a r e s u l t of several theories from the l i t e r a t u r e reviewed. The second part dealt with the d i f f e r e n t studies done on de-pendency during i l l n e s s and r e h a b i l i t a t i o n . The t h i r d part examined studies done on unemployment of patients with myo-c a r d i a l i n f a r c t i o n . The l i t e r a t u r e shows increasing s i g n i f i -cance of dependency during i l l n e s s and r e h a b i l i t a t i v e periods of human l i f e . Instruments used to obtain data relevant to the study were: Navran Dy, used to measure t r a i t dependency; D-I Scale, used to measure state dependency; and two structured question-naires pertaining to subject p r o f i l e and work p r o f i l e a f t e r discharge. The l a s t two questionnaires were developed a f t e r the l i t e r a t u r e was reviewed. The study population consisted of 21 male patients who suffered t h e i r f i r s t myocardial i n f a r c t i o n and who were con-fined i n one of the two general hospitals selected for the study. The study population was asked to answer questionnaires three times: on the 6th to 10th day after transfer to the Post Coronary Care Unit; on the week of discharge; and three months a f t e r discharge. 50 A g e , t h e number o f d a y s i n t h e C o r o n a r y C a r e U n i t , t h e number o f d a y s i n t h e P o s t C o r o n a r y C a r e U n i t , t h e s t a t e d e -p e n d e n c y s c o r e s o f t h e e m p l o y e d a n d u n e m p l o y e d g r o u p s , and t h e l o w t r a i t a n d h i g h t r a i t g r o u p s w e r e d e s c r i b e d a n d shown i n f r e q u e n c y d i s t r i b u t i o n t a b l e s . The d a t a c o l l e c t e d w e r e f u r t h e r a n a l y z e d t o t e s t t h e t h r e e h y p o t h e s e s : Mann W h i t n e y U T e s t f o r h y p o t h e s i s 1; a n d T w o - F a c t o r A n a l y s i s 6 f V a r i a n c e f o r h y p o t h e s e s 2 a n d 3. The r e s u l t s s howed t h a t : 1. A l t h o u g h t h e mean o f t h e N a v r a n Dy and t h e D e p e n d e n c y p o r -t i o n o f t h e D-I S c a l e s among t h e e m p l o y e d g r o u p a r e l o w e r t h a n t h a t o f t h e u n e m p l o y e d g r o u p , t h e r e i s n o s t a t i s t i c a l d i f f e r e n c e . 2. A l t h o u g h t h e e m p l o y e d g r o u p showed more c h a n g e s i n t h e De-p e n d e n c y p o r t i o n o f t h e D-I S c a l e t h a n t h e u n e m p l o y e d g r o u p d u r i n g t h e t w o t e s t i n g o c c a s i o n s , t h e r e i s no s t a t i s t i c a l s i g -n i f i c a n c e . 3. A l t h o u g h t h e l o w t r a i t g r o u p showed more c h a n g e s i n t h e De-p e n d e n c y p o r t i o n o f t h e D-I S c a l e t h a n t h e h i g h t r a i t g r o u p d u r i n g t h e two t e s t i n g o c c a s i o n s , t h e r e i s n o s t a t i s t i c a l s i g -n i f i c a n c e . I I . CONCLUSIONS A f t e r t h e a n a l y s i s o f t h e d a t a , t h e f o l l o w i n g c o n -c l u s i o n s w e r e made f o r t h i s s t u d y p o p u l a t i o n : 1. T h a t p a t i e n t s w i t h m y o c a r d i a l i n f a r c t i o n show d i f f e r e n t d e g r e e s o f t r a i t a n d s t a t e d e p e n d e n c y . 51 2. T h a t t r a i t d e p e n d e n c y i s n o t r e l a t e d t o w o r k r e s u m p t i o n o f p a t i e n t s w i t h m y o c a r d i a l i n f a r c t i o n . R e g a r d l e s s o f t h e t r a i t d e p e n d e n c y o f t h e s u b j e c t s , some w e n t b a c k t o w o r k w h i l e o t h e r s d i d n o t . I t i s p o s s i b l e t h a t t h e s m a l l number o f t h e s t u d y p o p u l a t i o n h a s a f f e c t e d t h e a n a l y s i s o f t h e d a t a . 3. T h a t s t a t e d e p e n d e n c y d o e s n o t c h a n g e s i g n i f i c a n t l y d u r i n g d i f f e r e n t s t a g e s o f i l l n e s s o f p a t i e n t s w i t h m y o c a r d i a l i n -f a r c t i o n . T h i s f i n d i n g i s c o n t r a r y t o t h e f i n d i n g s o f p r e v i o u s a u t h o r s l i k e D e r d i a r i a n a n d C l o u g h , who f o u n d i n t h e i r s t u d y t h a t s t a t e d e p e n d e n c y v a r i e s d u r i n g t h e p r e h o s p i t a l i z a t i o n t o p o s t d i s c h a r g e c o n t i n u u m . T h e r e w a s , h o w e v e r , a d i f f e r e n c e i n t h e t o t a l means o f s t a t e d e p e n d e n c y d u r i n g t h e two t e s t i n g o c c a s i o n s e v e n t h o u g h t h e d i f f e r e n c e was n o t s t a t i s t i c a l l y s i g n i f i c a n t . The s m a l l number o f t h e s a m p l e may h a v e a b e a r i n g on t h e r e s u l t o f t h i s s t u d y . 52 I I I RECOMMENDATIONS I n v i e w o f t h e p r e c e e d i n g r e s u l t s and c o n c l u s i o n s , t h e f o l l o w i n g r e c o m m e n d a t i o n s a r e made: 1. R e g a r d i n g r e s e a r c h , t h a t : a) a s t u d y o f l a r g e r a n d more v a r i e d p o p u l a t i o n be c o n d u c t e d . b) s u b j e c t s s h o u l d be a s k e d t o a n s w e r q u e s t i o n n a i r e s w h i l e s t i l l i n t h e C o r o n a r y C a r e U n i t and t h r e e d a y s a f t e r t h e y a r e t r a n s f e r r e d t o t h e P o s t C o r o n a r y U n i t . c) q u e s t i o n n a i r e s r e g a r d i n g w o r k r e s u m p t i o n be a n s w e r e d f o u r m onths and e i g h t m o n t h s a f t e r d i s c h a r g e . 2. R e g a r d i n g e d u c a t i o n , t h a t : a) t h e c o n c e p t o f d e p e n d e n c y s h o u l d be t a u g h t t o s t u d e n t s s o t h a t t h e y w i l l b e a w a r e o f i t s d i f f e r e n t d e g r e e s among p a t i e n t s , and t h e y w i l l b e e n c o u r a g e d t o c o n d u c t more r e s e a r c h i n t h i s a r e a . b) s t a f f n u r s i n g d e v e l o p m e n t s h o u l d i n c l u d e t h e c o n c e p t o f d e p e n d e n c y i n i t s p r o g r a m t o make n u r s e s a w a r e o f t h e v a r y i n g d e g r e e s o f d e p e n d e n c y among p a t i e n t s . 3. 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" M i n o r M a l a d j u s t m e n t s o f t h e A g e d . " A m e r i c a n H andbook o f P s y c h i a t r y , A r i s t e , S i l v a n o a n d B r o d y , ' E u g e n e e d s . (New Y o r k : B a s i c B o o k s , I n c . , 1974) : 8 5 0 - 8 5 1 . G o l d i n , G e o r g e e t a l . D e p e n d e n c y and I t s I m p l i c a t i o n t o  R e h a b i l i t a t i o n . R e v i s e d e d i t i o n . ( M a s s a c h u s e t t s : D. C. H e a t h and Company, 1 9 7 2 ) . L a l o n d e , M a r c . A New P e r s p e c t i v e on t h e H e a l t h o f C a n a d i a n s : A W o r k i n g Document ( O t t a w a : A p r i l 197 4 ) : 14. L e d e r e r , H e n r y . "How t h e S i c k V i e w T h e i r W o r l d . " S o c i a l  I n t e r a c t i o n a n d P a t i e n t C a r e , S k i p p e r , James e d . ( P h i l a d e l p h i a : L i p p i n c o t t a n d Co., 1 9 6 5 ) : 1 5 5 - 1 6 6 . P a r s o n s , T a l c o t t . " H e a l t h a n d I l l n e s s B e h a v i o u r : The S i c k R o l e D e f i n i t i o n s o f H e a l t h a n d I l l n e s s i n L i g h t o f A m e r i c a n V a l u e s and S o c i a l S t r u c t u r e . " P a t i e n t s ,  P h y s i c i a n s a n d I l l n e s s , 2 nd e d . (New Y o r k : 1 9 7 2 ) : 1 0 5 - 1 2 7 . S e c o r , J a n e . C o r o n a r y C a r e : A C o m p r e h e n s i v e N u r s i n g S p e c i a l t y (New Y o r k : A p p l e t o n - C e n t u r y - C r o f t s , 1 9 7 1 ) . T y r o n , P h y l l i s a n d L e o n a r d , R o b e r t . " G i v i n g t h e P a t i e n t An A c t i v e R o l e . " S o c i a l I n t e r a c t i o n a nd P a t i e n t C a r e , S k i p p e r , James e d . ( P h i l a d e l p h i a : L i p p i n c o t t a nd Co., 1 9 6 5 ) : 26. PERIODICALS A n d r e o l i , K a t h l e e n a n d F o s t e r , S u e . " B e h a v i o u r F o l l o w i n g A c u t e M y o c a r d i a l I n f a r c t i o n . 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"A P s y c h o d y n a m i c E v a l u a t i o n o f P a t i e n t s w i t h M y o c a r d i a l I n f a r c t i o n w i t h R e g a r d t o T h e i r F u t u r e O c c u p a t i o n a l and S o c i a l A d j u s t m e n t s . " P s y c h o t h e r a p y and P s y c h o s o m a t i c s 18 ( 1 9 7 0 ) : 2 9 4 - 2 9 8 . B r o u s t e t , J . P. e t a l . . " R e h a b i l i t a t i o n o f t h e C o r o n a r y P a t i e n t s : M o b i l i z a t i o n P r o g r a m i n t h e A c u t e P h a s e . " S c h w e i z e r i s c h e M e d i z i n i s c h e W o c h e n s c h r i f t 103 ( J a n u a r y 1 9 7 3 ) : 5 7 - 6 3 . C a r r o l , D. G. " C a r d i a c R e h a b i l i t a t i o n P a r t I I I : F o l l o w - u p a f t e r M y o c a r d i a l I n f a r c t i o n . " M a r y l a n d M e d i c a l  J o u r n a l 17 ( 1 9 6 8 ) : 7 8 . C a y , E l i z a b e t h e t a l . . " R e t u r n t o Work A f t e r a H e a r t A t t a c k . " J o u r n a l o f P s y c h o s o m a t i c M e d i c i n e 17 ( 1 9 7 3 ) : 2 3 1 - 2 4 6 . D e r d i a r i a n , A n a y i s K o u y o u m j i a n . "An A n a l y s i s o f D e p e n d e n c e , I n d e p e n d e n c e B e h a v i o u r V a r i a b l e s i n S u r g i c a l P a t i e n t s w i t h E m p h a s i s D i r e c t e d t o T r a i t a nd S t a t e D e p e n d e n c e . " J o u r n a l o f N u r s i n g R e s e a r c h ( J a n u a r y - F e b r u a r y 197 0 ) . E i n i n g e r , M a r y Ann a n d H i l l , J o h n . " I n s t r u m e n t a l a n d A f f e c t i o n a l D e p e n d e n c y and N u r t u r a n c e i n P r e S c h o o l C h i l d r e n . " The J o u r n a l o f G e n e t i c P s y c h o l o g y 115 ( 1 9 6 9 ) : 2 7 7 - 2 8 4 . F e j f a r , Z. " P r o b l e m s a n d C h a l l e n g e s i n R e h a b i l i t a t i o n o f P a t i e n t s w i t h A c u t e M y o c a r d i a l I n f a r c t i o n . " S c h w e i z e - r i s c h e M e d i z i n i s c h e W o r c h e n s c h r i f t 103 ( J a n u a r y 1 9 7 3 ) : 3 5 - 4 0 . G r a n t , A l b e r t and C o h e n , S t a n l e y . " A c u t e M y o c a r d i a l I n f a r c t i o n : E f f e c t o f a R e h a b i l i t a t i o n P r o g r a m on L e n g t h o f H o s p i t a l i -z a t i o n and F u n c t i o n a l S t a t u s o f D i s c h a r g e . " A r c h i v e s  P h y s i c a l M e d i c i n e R e h a b i l i t a t i o n 54 ( A p r i l 1 9 7 3 ) : 2 0 1 - 2 0 7 . 61 H a c k e t t , T . P . a n d W e i s m a n , A . D . " D e n i a l A s A F a c t o r I n P a t i e n t s W i t h H e a r t D i s e a s e a n d C a n c e r . " A n n a l s  o f t h e N e w Y o r k A c a d e m y o f S c i e n c e s 16 4 ( D e c e m b e r 1 9 6 9 ) : 8 0 2 - 8 1 7 . H e a t h e r s , G l e n . " E m o t i o n a l D e p e n d e n c e a n d I n d e p e n d e n c e i n N u r s e r y S c h o o l P l a y . " T h e J o u r n a l o f G e n e t i c P s y - c h o l o g y 3 7 ( 1 9 5 5 ) : 3 7 -57. H e a t h e r s , G l e n . " A c q u i r i n g D e p e n d e n c e a n d I n d e p e n d e n c e : A T h e o r e t i c a l O r i e n t a t i o n . " T h e J o u r n a l o f G e n e t i c  P s y c h o l o g y 87 ( 1 9 5 5 ) : 2 7 7 - 2 9 1 . K e l l e r m a n , J . J . " P h y s i c a l C o n d i t i o n i n g i n P a t i e n t s A f t e r M y o c a r d i a l I n f a r c t i o n : R e s u l t s o f A C o m p a r a t i v e S t u d y A n d 9 Y e a r ' s F o l l o w - u p . " S c h w e i z e r i s c h e M e d i z i n i s c h e  W o r c h e n s c h r i f t 103 ( J a n u a r y 1 9 7 3 ) : 7 9 - 3 5 . M i k u l i c , M a r y A n n . " R e i n f o r c e m e n t o f I n d e p e n d e n t a n d D e p e n -d e n t B e h a v i o u r s B y N u r s i n g P e r s o n n e l : A n E x p l o r a t o r y S t u d y . " T h e N u r s i n g R e s e a r c h 20 ( M a r c h - A p r i l 1 9 7 1 ) : 1 6 2 - 1 6 5 . N a g l e , R o b e r t a n d G a n g o l a , R a j a n . " F a c t o r s I n f l u e n c i n g R e t u r n T o W o r k A f t e r M y o c a r d i a l I n f a r c t i o n . " L a n c e t 2 ( A u g u s t 1 9 7 1 ) : 4 5 4 - 4 5 6 . R o s e n , J a c q u e l i n e a n d B i b r i n g , G r e t a . " P s y c h o l o g i c a l R e a c t i o n s o f H o s p i t a l i z e d M a l e P a t i e n t s t o a H e a r t A t t a c k : A g e a n d S o c i a l D i f f e r e n c e s . " P s y c h o s o m a t i c M e d i c i n e 2 8 ( 1 9 6 6 ) : 8 0 8 - 8 2 0 . R u s k i n , H . D . , e t a l . . " M M P I : C o m p a r i s o n B e t w e e n P a t i e n t s W i t h C o r o n a r y H e a r t D i s e a s e a n d T h e i r S p o u s e s T o g e t h e r W i t h O t h e r D e m o g r a p h i c D a t a . " S c a n d i n a v i a n J o u r n a l o f  R e h a b i l i t a t i v e M e d i c i n e 2 ( 1 9 7 0 ) : 9 9 - 1 0 4 . S c a l z i , . C y n t h i a . " N u r s i n g M a n a g e m e n t o f B e h a v i o u r a l R e s p o n s e s F o l l o w i n g a n A c u t e M y o c a r d i a l I n f a r c t i o n . " T h e H e a r t - L u n g M a g a z i n e ( J a n u a r y - F e b r u a r y 1 9 7 3 ) : 6 2 - 6 9 . S e x t o n , A . G . a n d W i c k , R o b e r t L . " F i f t e e n - Y e a r S u r v e y o f P i l o t s R e t u r n e d T o F l y i n g S t a t u s F o l l o w i n g a M y o c a r d i a l I n f a r c t i o n . " A e r o s p a c e M e d i c i n e ( N o v e m b e r 1 9 7 3 ) : 1 2 8 7 -1 2 8 9 . S h a p i r o , S a m , W e i n b l a t t , E v e , a n d F r a n k , C h a r l e s . " R e t u r n t o W o r k A f t e r F i r s t M I . " A r c h i v e s o f E n v i r o n m e n t a l H e a l t h 24 ( J a n u a r y 1 9 7 2 ) : 1 7 - 2 6 . 62 S h i l l e r , E r i c . " C a r d i a c R e h a b i l i t a t i o n : I t s P o t e n t i a l i n t h e E a r l y P r e v e n t i o n o f D i s a b i l i t y A f t e r M y o c a r d i a l I n f a r c t i o n . " The M e d i c a l J o u r n a l o f A u s t r a l i a 2 ( 1 9 7 2 ) : 7 5 1 - 7 5 7 . S o r e n s o n , G l a d y s . " D e p e n d e n c y : A F a c t o r I n N u r s i n g C a r e . " A m e r i c a n J o u r n a l o f N u r s i n g 66 ( A u g u s t 1 9 6 6 ) : 1 7 6 2 - 1 7 6 3 . S t o t s k y , B e r n a r d . " S o c i a l , P s y c h o l o g i c a l F a c t o r s i n Depen-d e n c y . " R e h a b i l i t a t i o n R e c o r d 4 ( J u l y - A u g u s t 1 9 6 3 ) : 8-9. V u o p o l a , U n t o . " R e s u m p t i o n o f Work A f t e r M y o c a r d i a l I n f a r c t i o n I n N o r t h e r n I r e l a n d . " A c t a M e d i c a S c a n d i n a v i c a S u p p l e - m e n t a ( 1 9 7 2 ) : 5 2 7 - 5 3 3 . W i n c o t t , E l i z a b e t h a . " R e t u r n t o Work A f t e r M y o c a r d i a l I n -f a r c t i o n . " B r i t i s h M e d i c a l J o u r n a l 26 (November 1 9 6 6 ) : 1302-1304.' W i s h n i e , H. A. e t a l . . " P s y c h o l o g i c a l H a z a r d s o f C o n v a l e s c e n c e A f t e r M y o c a r d i a l I n f a r c t i o n . " A m e r i c a n M e d i c a l A s s o c i a - t i o n J o u r n a l 215 ( F e b r u a r y 2 2 , 1 9 7 1 ) : 1 2 9 2 - 1 2 9 6 . Wynn, A. " U n w a r r a n t e d E m o t i o n a l D i s t r e s s o f C o n v a l e s c e n c e A f t e r M y o c a r d i a l I n f a r c t i o n . " M e d i c a l J o u r n a l o f A u s t r a l i a ( 1 9 6 7 ) : 8 4 7 - 8 5 1 . OTHER Ad h o c C o m m i t t e e on t h e E x p a n d e d R o l e , "A D e s c r i p t i v e S u r v e y o f t h e E x p a n d e d R o l e o f t h e N u r s e i n t h e H e a l t h S c i e n c e C e n t r e . " The N u r s i n g D i v i s i o n H e a l t h S c i e n c e H o s p i t a l , D e p a r t m e n t o f P s y c h i a t r y , U n i v e r s i t y o f B r i t i s h C o l u m b i a , 1 9 7 3 . A l l e m a n g , M a r g a r e t , The E x p e r i e n c e s o f E i g h t C a r d i a c P a t i e n t s  D u r i n g a P e r i o d o f H o s p i t a l i z a t i o n i n a G e n e r a l H o s p i t a l ( T o r o n t o : 1 9 6 0 ) . C a n a d i a n M i n i s t r y o f I n d u s t r y , T r a d e and Commerce, S t a t i s t i c s C a n a d a , H e a l t h D i v i s i o n , H o s p i t a l M o r b i d i t y ( O t t a w a , O n t a r i o : 197 2) . C a n a d i a n M i n i s t r y o f I n d u s t r y , T r a d e a n d Commerce, S t a t i s t i c s C a n a d a , H e a l t h D i v i s i o n , C a u s e s o f D e a t h : P r o v i n c e s b y  S e x , a n d C a n a d a b y S e x and Age ( O t t a w a , O n t a r i o : 1 9 7 2 ) . 63 C l a p p , W i l l i a m F o r d . " D e p e n d e n c e and C o m p e t e n c e i n C h i l d r e n : P a r e n t a l T r e a t m e n t o f F o u r - y e a r - o l d B o y s . " D i s s e r t a t i o n  A b s t r a c t s 28 ( 1 9 6 7 ) : 1 7 0 3 . M o o r e , J a m e s . " A n t e c e d e n t s o f D e p e n d e n c y and Autonomy, i n Y o u n g C h i l d r e n . " D i s s e r t a t i o n A b s t r a c t s 26 ( 1 9 6 5 ) : 1 7 6 6 . N e l s o n , J o h n W a l t e r . " D e p e n d e n c y As A C o n s t r u c t : An E v a l u -a t i o n a n d Some D a t a . " D i s s e r t a t i o n A b s t r a c t s 19 ( 1 9 5 9 ) : 2 1 4 9 . R o t h b e r g , J u n e Simmonds. " D e p e n d e n c e and A n x i e t y i n M a l e P a t i e n t s F o l l o w i n g S u r g e r y : An I n v e s t i g a t i o n o f t h e R e l a t i o n s h i p B e t w e e n D e p e n d e n c e , A n x i e t y and P h y s i c a l M a n i f e s t a t i o n o f R e c o v e r y F o l l o w i n g S u r g e r y i n M a l e P a t i e n t s . " . D i s s e r t a t i o n A b s t r a c t s 27 ( 1 9 6 6 ) : 5 2 5 - 5 2 6 . 64 APPENDIX A 65 C o n s e n t t o P a r t i c i p a t e Code Number H o s p i t a l Number I , , a g r e e t o p a r t i c i p a t e i n a s t u d y a t h o s p i t a l . The s t u d y i s a b o u t moods a n d f e e l i n g s , a n d w o r k r e s u m p t i o n o f p a t i e n t s w i t h m y o c a r d i a l i n f a r c t i o n . I u n d e r s t a n d t h a t : 1) t h e s t u d y w i l l i n v o l v e a n s w e r i n g two s e t s o f q u e s t i o n n a i r e s . a) on my 6 t h - 1 0 t h d a y a t t h e P o s t - C o r o n a r y Ward b) o n t h e l a s t week b e f o r e d i s c h a r g e c) on t h e t h i r d m o n t h a f t e r my d i s c h a r g e 2) t h e q u e s t i o n n a i r e s , w h i c h w i l l t a k e a b o u t h a l f an h o u r , w i l l b e a n s w e r e d i n my c o n v e n i e n c e . 3) no r i s k s a r e i n v o l v e d a n d n o names w i l l be u s e d . 4) I am f r e e t o w i t h d r a w f r o m t h e s t u d y a t any t i m e . 5) o n r e q u e s t , I w i l l b e i n f o r m e d o f t h e r e s u l t s . S i g n a t u r e o f P a r t i c i p a n t : S i g n a t u r e o f R e s e a r c h e r : D a t e : 66 APPENDIX B 67 S u b j e c t ' s P r o f i l e Q u e s t i o n n a i r e Code Number H o s p i t a l Number .. K i n d l y w r i t e t h e number o f y o u r a n s w e r s o n t h e r i g h t - h a n d s i d e o f t h e q u e s t i o n n a i r e . 1. S e x 1) F e m a l e 2) M a l e 1 2. What i s y o u r m a r i t a l s t a t u s ? 1) S i n g l e 4) S e p a r a t e d 2) M a r r i e d 5) D i v o r c e d 3) Widowed 6) O t h e r 2 3. What i s y o u r p r e s e n t a g e r a n g e ? 1) 30 y e a r s o r u n d e r 3) 41-50 y e a r s 2) 31-40 y e a r s 4) 51-60 y e a r s 3 4. A r e y o u p r e s e n t l y e m p l o y e d 1) Y e s 2) NO 4 5. Were y o u w o r k i n g f u l l t i m e b e f o r e y o u r h o s p i t a l i z a t i o n ? 1) Y e s 2) No 3) O t h e r ( s p e c i f y ) 5 6. HOW l o n g h a v e y o u b e e n w o r k i n g f u l l t i m e ? 1) L e s s t h a n 6 m o n t h s 4) 10 t o 15 y e a r s 2) 6 m o n t h s t o 5 y e a r s 5) M o r e t h a n 15 3) 5 t o 10 y e a r s y e a r s 6 7. What i s y o u r u s u a l o c c u p a t i o n ? 1) H i g h e x e c u t i v e , p r o p r i e t o r o f l a r g e c o n c e r n a n d m a j o r p r o f e s s i o n a l s 2) B u s i n e s s m a n a g e r , p r o p r i e t o r o f medium s i z e d b u s i n e s s a n d o t h e r p r o f e s s i o n a l s . 3) A d m i n i s t r a t i v e p e r s o n n e l and p r o p r i e t o r o f s m a l l i n d e p e n d e n t b u s i n e s s 4) C l e r i c a l , s a l e s w o r k e r and t e c h n i c i a n 5) S k i l l e d m a n u a l e m p l o y e e 6) M a c h i n e o p e r a t o r a n d s e m i - s k i l l e d e m p l o y e e 7) U n s k i l l e d e m p l o y e e 8) O t h e r ( s p e c i f y ) 7 8. How many h o u r s e a c h d a y d i d y o u w o r k p r i o r t o . y o u r p r e s e n t a d m i s s i o n ? 1) L e s s t h a n 4 h o u r s a d a y 2) B e t w e e n 4-8 h o u r s a d a y 3) M o r e t h a n 8 h o u r s a d a y 4) O t h e r ( s p e c i f y ) 8 68 Work R e s u m p t i o n Q u e s t i o n n a i r e Code Number.... H o s p i t a l Number K i n d l y w r i t e t h e number o f y o u r a n s w e r s on t h e r i g h t - h a n d s i d e o f t h e q u e s t i o n n a i r e . 1. A r e y o u w o r k i n g now? 1) Y e s 2) No 3) O t h e r ( s p e c i f y ) 1 I f y o u a r e h o t w o r k i n g now, k i n d l y s t a t e t h e r e a s o n ( s ) f o r n o t r e t u r n i n g t o w o r k . 2. How l o n g h a v e y o u b e e n w o r k i n g s i n c e y o u r d i s c h a r g e ? 1) N o t a p p l i c a b l e 2) L e s s t h a n 2 weeks 3) M o r e t h a n 2 weeks b u t l e s s t h a n a m o n t h 4) More t h a n a m o n t h 2 3. Do y o u h a v e t h e same j o b ? 1) N o t a p p l i c a b l e 2) Y e s 3) No ( s p e c i f y ) 3 4. Do y o u s p e n d t h e same number o f h o u r s a t w o r k as y o u d i d b e f o r e y o u r h o s p i t a l i z a t i o n ? 1) N o t a p p l i c a b l e 2) Y e s 3) No ( s p e c i f y ) 4 69 N a v r a n Dy TRUE - FALSE QUESTIONNAIRE C o d e N u m b e r  H o s p i t a l Number. P l e a s e mark a "T" b e s i d e e a c h s t a t e m e n t t h a t i s t r u e , o r m o s t l y t r u e  a s a p p l i e d t o y o u , and a n "F" b e s i d e e a c h s t a t e m e n t t h a t i s f a l s e o r  n o t u s u a l l y t r u e as a p p l i e d t o y o u . I f a s t a t e m e n t d o e s n o t a p p l y t o y o u o r i f i t i s s o m e t h i n g t h a t y o u d o n ' t know a b o u t , l e a v e t h e s p a c e b l a n k . Remember t o g i v e y o u r own o p i n i o n o f y o u r s e l f . Do n o t l e a v e a n y  s p a c e b l a n k i f y o u c a n a v o i d i t . T r y t o make some a n s w e r t o e v e r y s t a t e m e n t . 9. I am a b o u t a s a b l e t o w o r k a s I e v e r was. 19. When I t a k e a new j o b , I l i k e t o be t i p p e d o f f on who s h o u l d be g o t t e n n e x t t o . 21. A t t i m e s I h a v e v e r y much w a n t e d t o l e a v e home. 24. No one seems t o u n d e r s t a n d me. 41. I h a v e h a d p e r i o d s o f d a y s , w e e k s , o r months when I c o u l d n ' t a k e c a r e o f t h i n g s b e c a u s e I c o u l d n ' t " g e t g o i n g . " 65. I l o v e d my f a t h e r . 67. I w i s h I c o u l d be a s h a p p y a s o t h e r s seem t o b e . _70. I u s e d t o l i k e d r o p - t h e - h a n d k e r c h i e f . _79. My f e e l i n g s a r e n o t e a s i l y h u r t . 82. I am e a s i l y downed i n a n a r g u m e n t . _86. I am c e r t a i n l y l a c k i n g i n s e l f - c o n f i d e n c e . 9 8. I b e l i e v e i n t h e s e c o n d c o m i n g o f C h r i s t . 100. I h a v e met p r o b l e m s s o f u l l o f p o s s i b i l i t i e s t h a t I h a v e b e e n u n a b l e t o make up my m i n d a b o u t them. JL07. I am h a p p y m o s t o f t h e t i m e . 138. C r i t i c i s m o r s c o l d i n g h u r t s me t e r r i b l y . 141. My c o n d u c t i s l a r g e l y c o n t r o l l e d b y t h e c u s t o m s o f t h o s e a b o u t me. _158. I c r y e a s i l y . 163. I do n o t t i r e q u i c k l y . 165. I l i k e t o know some i m p o r t a n t p e o p l e b e c a u s e i t makes me f e e l i m p o r t a n t . 70 17 0 . What o t h e r s t h i n k o f me d o e s n o t b o t h e r me. 180. I f i n d i t h a r d t o make t a l k when I meet new p e o p l e . 189. I f e e l weak a l l o v e r much o f t h e t i m e . .19 3. I do n o t h a v e s p e l l s o f h a y f e v e r o r a s t h m a . 2 0 1 . I w i s h I w e r e n o t s o s h y . 212. My p e o p l e t r e a t me more l i k e a c h i l d t h a n a g r o w n - u p . 236. I b r o o d a g r e a t d e a l . 239. I h a v e b e e n d i s a p p o i n t e d i n l o v e . 259. I h a v e d i f f i c u l t y i n s t a r t i n g t o do t h i n g s . 2 6 4 . I am e n t i r e l y s e l f - c o n f i d e n t . 2 67. When i n a g r o u p o f p e o p l e I h a v e t r o u b l e t h i n k i n g o f t h e r i g h t t h i n g s t o t a l k a b o u t . 304. I n s c h o o l I f o u n d i t v e r y h a r d t o t a l k b e f o r e t h e c l a s s . 3 0 5 . E v e n when I am w i t h p e o p l e I f e e l l o n e l y much o f t h e t i m e . 3 2 1 . I am e a s i l y e m b a r r a s s e d . 337. I f e e l a n x i e t y a b o u t s o m e t h i n g o r someone a l m o s t a l l t h e t i m e . 338. I h a v e c e r t a i n l y h a d more t h a n my s h a r e o f t h i n g s t o w o r r y a b o u t . 343. I u s u a l l y h a v e t o s t o p a nd t h i n k b e f o r e I a c t e v e n i n t r i f l i n g m a t t e r s . 357. I h a v e s e v e r a l t i m e s g i v e n up d o i n g a t h i n g b e c a u s e I t h o u g h t t o o l i t t l e o f my a b i l i t y . 3 6 1 . I am i n c l i n e d t o t a k e t h i n g s h a r d . _362. I am more s e n s i t i v e t h a n m o s t p e o p l e . _369. R e l i g i o n g i v e s me no w o r r y . 3 7 5 . When I am f e e l i n g v e r y h a p p y and a c t i v e , someone who i s b l u e o r l o w w i l l s p o i l i t a l l . _382. I w i s h I c o u l d g e t o v e r w o r r y i n g a b o u t t h i n g s I h a v e s a i d t h a t may h a v e i n j u r e d o t h e r p e o p l e ' s f e e l i n g s . 71 3 83. P e o p l e o f t e n d i s a p p o i n t me. 390. I h a v e o f t e n f e l t b a d l y o v e r b e i n g m i s u n d e r s t o o d when t r y i n g t o k e e p someone f r o m m a k i n g a m i s t a k e . 39 4. I f r e q u e n t l y a s k p e o p l e f o r a d v i c e . 397. I h a v e s o m e t i m e s f e l t t h a t d i f f i c u l t i e s w e r e p i l i n g up s o h i g h t h a t I c o u l d n o t o v e r c o m e them. 398. I o f t e n t h i n k , " I w i s h I w e r e a c h i l d a g a i n . " 4 08. I am a p t t o h i d e my f e e l i n g s i n some t h i n g s . , t o t h e p o i n t t h a t p e o p l e may h u r t me w i t h o u t t h e i r k n o w i n g a b o u t i t . 4 43. I am a p t t o p a s s up s o m e t h i n g I w a n t t o do b e c a u s e o t h e r s f e e l t h a t I am n o t g o i n g a b o u t i t i n t h e r i g h t way. 4 87. I f e e l l i k e g i v i n g up q u i c k l y when t h i n g s go w r o n g . 488. I p r a y s e v e r a l t i m e s e v e r y week. 4 89. I f e e l s y m p a t h e t i c t o w a r d s p e o p l e who t e n d t o hand o n t o t h e i r g r i e f s and t r o u b l e s . 509. I s o m e t i m e s f i n d i t h a r d t o s t i c k up f o r my r i g h t s b e c a u s e I am s o r e s e r v e d . 5 3 1 . P e o p l e c a n p r e t t y e a s i l y c h a n g e me e v e n t h o u g h I t h o u g h t t h a t my m i n d was a l r e a d y made up o n a s u b j e c t . 549. I s h r i n k f r o m f a c i n g a c r i s i s o r d i f f i c u l t y . 544. I f . I w e r e a n a r t i s t I w o u l d l i k e t o d r a w c h i l d r e n . 564. I am a p t t o p a s s up s o m e t h i n g I w a n t t o do when o t h e r s f e e l t h a t i t i s n ' t w o r t h d o i n g . Dependency P o r t i o n o f D-I S c a l e PLEASE CIRCLE THE NUMBER THAT BEST MATCHES HOW YOU WOULD DESCRIBE YOURSELF PRESENTLY, IN EACH OF THE FOLLOWING STATEMENTS. 1. I put my arm around my f r i e n d s , p a t them on the back, o r h o l d hands when we a r e c o n v e r s i n g . 2. I ask my f r i e n d s t o h o l d my hand, o r r e a c h o u t t o h o l d hands when I am u p s e t o r i n p a i n . 3. I r e a c h o u t f o r my f r i e n d ' s o r l o v e d one's hand when we a r e w a l k i n g t o g e t h e r o r a r e a l o n e . 4. I f e e l c o m f o r t a b l e when someone I am c l o s e t o reac h e s o u t t o h o l d my hand o r p a t me on t h e back when we a r e c o n v e r s i n g . 5. I t makes me f e e l b e t t e r when a f r i e n d o r l o v e d one r e a c h e s o u t t o h o l d my hand when I am u p s e t o r i n p a i n . 6. I f e e l c o m f o r t a b l e when someone c l o s e t o me p u t s an arm around my s h o u l d e r o r h o l d s my hand when we a r e w a l k i n g t o g e t h e r . 7. I s i t n e a r my f r i e n d s o r s t a y c l o s e t o them when we are w a t c h i n g TV, g o i n g on w a l k s t o g e t h e r , o r even when we a r e i n v o l v e d i n d i f f e r e n t t h i n g s . 8. I ask my f r i e n d s o r l o v e d ones t o s t a y w i t h me o r s i t n e a r me when I am d e p r e s s e d , u p s e t , o r i n p a i n . Code Number H o s p i t a l Number P r e s e n t l y , t h i s s t a tement b e s t d e s c r i b e s me: 1 2 3 4 5 not a t a l i t t l e m o d e r a t e l y f a i r l y v e r y a l l w e l l w e l l 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 9. I c a l l my f r i e n d s o n t h e p h o n e , o r , i n v i t e t h e m o v e r t o v i s i t . 10.. I am s o f t - s p o k e n . 1 1 . I t e l l p e o p l e t h a t I am c l o s e t o t h a t t h e i r f r i e n d s h i p means a l o t t o me. 12. I c a r r y p i c t u r e s o f my f a m i l y o r f r i e n d s i n my w a l l e t , a n d l o o k a t t h e p i c t u r e s when I am l o n e l y o r d e p r e s s e d . 13. I c a l l p e o p l e b y t h e i r f i r s t names, e v e n when I d o n ' t know them w e l l . 14. I t makes me s a d when my f r i e n d s h a v e t o l e a v e , a n d I w i l l a s k them i f t h e y c a n s t a y a l i t t l e l o n g e r . 15. I s t a n d o u t i n a c r o w d b e c a u s e o f my manner o f d r e s s o r a p p e a r a n c e . 16. I s p e a k l o u d l y , t o t h e p o i n t t h a t s o m e t i m e s p e o p l e a s k me t o l o w e r my v o i c e . 17. I do o r s a y t h i n g s j u s t t o s e e i f i t w i l l s h o c k p e o p l e . 18. I s a y h e l l o t o p e o p l e - t h a t p a s s me i n t h e s t r e e t o r h a l l w a y s e v e n t h o u g h I d o n ' t know them v e r y w e l l . P r e s e n t l y , t h i s s t a t e m e n t b e s t d e s c r i b e s me: 1 2 3 4 5 n o t a t a l i t t l e m o d e r a t e l y f a i r l y v e r y a l l w e l l w e l l 1 2 3 4 5 1 - 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 - 4 5 co 19. I ask f o r e x t r a s e r v i c e s when I am i n a r e s t a u r a n t o r o t h e r p l a c e s t h a t p r o v i d e customer s e r v i c e , s u c h as a beauty p a r l o r , b a r b e r shop o r h o s p i t a l . 20. I l i k e t o have o t h e r p e o p l e h e l p me make d e c i s i o n s , and w i l l ask f o r a d v i c e o r s u g g e s t i o n s . 21. I a c c e p t d e c i s i o n s made f o r me by o t h e r s , o r f o l l o w a d v i c e o f f e r e d . 22. I wonder a l o u d when I'm w i t h p e o p l e I know, s a y i n g t h i n g s l i k e , " I wonder what t h e r e s u l t s o f my t e s t w i l l be...whether I ' l l g e t t h a t p r o m o t i o n . . . " 23. I ask f o r r e a s s u r a n c e from o t h e r s by s a y i n g t h i n g s l i k e , "Do you t h i n k I l o o k a l l r i g h t ? " 24. I f i n d m y s e l f d e s c r i b i n g my d i f f i c u l t i e s a t l e n g t h t o f r i e n d s . 25. When I j u s t d o n ' t f e e l l i k e d o i n g some t h i n g s f o r m y s e l f , even though I am a b l e t o , I'm r e l i e v e d when someone o f f e r s t o h e l p me do t h e s e t h i n g s . 26. I ask pe o p l e I'm c l o s e t o i f th e y would do t h i n g s f o r me, even though I c o u l d do i t m y s e l f , s u c h as g e t t i n g me some a s p i r i n f o r a headache. P r e s e n t l y , t h i s statement b e s t d e s c r i b e s me: 1 2 3 4 5 not a t a l i t t l e m o d e r a t e l y f a i r l y v e r y a l l w e l l w e l l 1 1 1 2 1 2 1 2 27. I t e l l p e o p l e a b o u t a c c o m p l i s h m e n t s t h a t c l o s e f r i e n d s o r f a m i l y members h a v e made. 28. I t e l l p e o p l e a b o u t a c c o m p l i s h m e n t s I h a v e made. 29. I t r y t o h e l p p e o p l e , e i t h e r b y i n v o l v e m e n t i n c o m m u n i t y p r o j e c t s o r by o f f e r i n g d i r e c t a s s i s t a n c e , e s p e c i a l l y when I am g i v e n r e c o g n i t i o n o r p r a i s e f o r my e f f o r t s . 30. I do w h a t i s e x p e c t e d o f me r a t h e r t h a n c o m p l a i n , b e c a u s e p e o p l e d o n ' t l i k e a c o m p l a i n e r . 31. I compare m y s e l f t o o t h e r s , a n d t e l l p e o p l e t h a t I d i d o r c a n d o a b e t t e r j o b t h a n t h e o t h e r p e r s o n . P r e s e n t l y , t h i s s t a t e m e n t b e s t d e s c r i b e s me: 1 2 3 4 5 n o t a t a l i t t l e m o d e r a t e l y f a i r l y v e r y a l l w e l l w e l l 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 

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